NCC240537_FRO Submitted_20240226

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELLNo person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
COUNTY NC watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
- - Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning& Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name River Rock Easy Living at Blume Road
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Blume Road Latitude 35.570989 Longitude -80.907118
3. Approximate date land-disturbing activity will commence: April 6,2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.40 AC
6. Amount of fee enclosed: $ 3,500 . 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Holcomb E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
RRCAP FA Blume Road LLC 704-617-6874
Name Telephone Fax Number
517 Alcove Road,Suite 302 129 Blume Road
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 2483 Page No. 926 Provide a copy of the most current deed.
Part B. *Deed Book No. 753 Page No. 635 Provide a copy of the most current deed.
*Title tract 2 provided;address&contact information remains the same
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):
RRCAP FA Blume Road LLC [e-mail]
Name E-mail Address
517 Alcove Road,Suite 302 517 Alcove Road,Suite 302
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

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.
. C) L4 Acot of t
Type ore name Title or Authority
Ol — tl- 2o?.1"f-
.4111
Date
I, ( " iS('+J t( 0" Cat e a Notary Public of the County of I read I _
State of North Carolina, hereby certify that ,Sa/1 CL,k_ii-1�h appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this I u+ day of h -l- ,20
Notary
Seal I 0 I I t 9O (
My commission expires lT�')
Chasity Baucom Conner
NOTARY PUBLIC
Iredell County
North Carolina
LMy Commission Expires October 17,2026
Page 2 of 2