NCC240295_FRO Submitted_20240201

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
f EROSION & SEDIMENTATION CONTROL
IR E D E E L No person may initiate any land-disturbing activity on one or more acres, '/% acre or more inside a
watershed, as covered by the Sedimentation Pollution • 1 • • � S erlrede County Land
Development Code, before an acceptable erosion and s- •-`=. - ',n I ben submitted
and approved by the Iredell County Planning&Developme , • -•'• •
(Please type or print) NOV 1 5 2023
Part A.
1. Project Name Pine Spring Meadows
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Big Indian Loop Latitude 35.612899 Longitude-80.870826
3. Approximate date land-disturbing activity will commence: January 2023
4. Purpose of development(residential,commercial, industrial,institutional, etc.) Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 350 . An application fee of$175.00 per acre (rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed l
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bobby Fertig E-mail Address bobbyAlakemisthomes.com
Telephone Cell# 828-514-4239 Fax#
9. Landowner(s) of Record(attach accompanied page to list additional owners):
Lakeshore Holdings, LLC dba Lakemist Homes 704-799-7609
Name Telephone Fax Number
PO Box 5350 637 Williamson Rd, Suite 2
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 2996 Page No.1428 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
Lakeshore Holdings, LLC dba Lakemist Homes [e-mail]
Name E-mail Address
PO Box 5350 637 Williamson Rd, Suite 2
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina Agent
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b)If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach
a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address of the Registered Agent
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath (This form
must be signed by the Financially Responsible Person if an individual or his attorney-in-fact, or if not an individual, by an officer,
director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Person). I agree to
provide corrected information should there by any change in the information provided herein.
J�1r/' P/dKKC�r`JA 014,1a'tr
Type or prrn{name Title or Authority
Si nature Date
I, Eli IA"- f ( y ) p,/ , a Notary Public of the County of ttej USe
State of North Carolina, hereby certify thatowIctS appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
i1(L Witness my hand and notarial seal, this _day of M'-
__ Q(}1an , 20 a
Nota
Seal
My commission expires 1� e
ER1N E GORDON
Notary PutAlo
Iredell Co,, North Carta
My Commission Expired Jan.28,2028
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