NCC240900_FRO Submitted_20240401

i -in ..
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
410, EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres. '/ 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 8 Development, Erosion Control Section
Please type or print)
Part A.
1 Project Name L Pr - Mb(i \AJ CAS>rt e je j-bi't e S
2 Location of land-disturbing activity County,(e ck e-1 t City or Township_ jk1X(est I Ile_
Highwayi treet ✓3 �'� e &L 12 Latitude 3Z , 5.(p 3 J Longitude FOi 9 / d 0
S �Sle of -PANes
3 Approximate date land-disturbing activity will commence 11� a oa`I
4Purpose of development (residential, commercial, industrial, institutional, etc ) 3 Res I c /
I es '
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas) 0 ' .
6 Amount of fee enclosed $ Sa 5T,D U 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 5100 00 is assessed
7 Has an erosion and sediment control plan been filed? Yes No Enclosed )(-
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name aehe NBC CCJLf1rie m e C Q r 6) Pie . ��
E-mailE-mail Address
Telephone ( Cell # go -at-to "-) t'. Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners)
`ems Ate ( .. Dc2, q,fvVo-7b / i
Name Lpb(e to1Vtb C A f rtA Hojim2Sjelephone Fax Number
l (o Rol 1In ,. LA)04)cL LIJ ("Le _ l_lD Rd'i>n ri 044 Lk)
Current Mailing AddreisA Current Street Addre
NI Ca v•S u I le IU C a s l l-7 fYoesiJ1( 1JC o81 /e)
City State Zip City State Zip
10 Deed Book No 01-1 1 Page No j?VC 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)
6iNe- Ae cal — erte cclrr- _iQ_t e , tom\_
flame
E- it Address
WO
P(Ah fliktvi4_ IVCurrant Street Address
V
Current MillingMIdres9
Moors v,1 k NC 4 Ru 7 - -
City State Zip City State lily ,i
qg) - ,)yo -'7b/�.
telephone Fax Number
I ' lip. 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 Carol na Agent
(VIp
Name E-mail Address
i
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
a
(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
I
NIax
Name of Registered Agent E-mail Address
I
' 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
&erta MC e IA7 P,' id - C4/4 M64^4, Cri-rrii ' H s
Type or print name Title or Authority
fl----/8-- PIZ 2 ) --------Mg-te z__ 4- et)c)1.
ignature o Date
1,—. 4%-eA• 'E4(l c2' , a Notary Public of the County of I,kre L�.(
State of North Carolina, hereby certify that amp . j He �- y appeared personally before me this day
and being duly sworn acknowledged that the a ;j.QA�e form was executed by hi
Witness my hand and notanal seal, this `-e day of WO4eCfrA . 20 g4
E.La34"&---
1%rili4;*t
Seal
�. ..... My commission expires_( _{irai sc ian_ .'lies
i r ,td t J E ti� 03/14/2028
i' -.9 b r r
r .r
r- C O Pr
9C1O` I.
f'rujo 2 of 2