NCC241153_FRO Submitted_20240415

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
RED E L L No person may initiate any land-disturbing activity on one or more acres, Yz acre or more inside a
;) ; e 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 Peninsula Baptist Church Proposed Parking Addition
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Brawley School Road Latitude 35.57976 Longitude-80.87838
3. Approximate date land-disturbing activity will commence: Upon plan approval
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Institutional (Church)
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.26 Ac
6. Amount of fee enclosed:$ 525.00 . 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 David Bolling E-mail Address [e-mail]
Telephone [phone] Cell# 336-451-1414 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Peninsula Baptist Church/Steve Mangum 704-664-2958 704-664-3991
Name Telephone Fax Number
687 Brawley School Road 687 Brawley School Road
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 1358 Page No. 1 173 Provide a copy of the most current deed.
1475 2163
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):
Peninsula Baptist Church [e-mail]
Name E-mail Address
687 Brawley School Road 687 Brawley School Road
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number 704-664-3991
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:
Robert H. Jackson, Jr. [e-mail]
Name of Registered Agent E-mail Address
687 Brawley School Road 687 Brawley School Road
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] 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.
SivitterStriWeR D. Mangum Executive Pastor
Type or print name Title or Authority
s 4444,dal 3 /1 f 2a 24
rgnature Date
�
1'�7�en y ,allo Public of the County of .J-1/-� �//
State of North Carolina, hereby certify that .�/1tary 2P1cf1 2. 41llr? L rru appeared personally before me this day
and being duly sworn acknowledged that the above form was executed byim.
Witness my hand and notarial seal,this /9 day of 4/ki/d2 ,20 aIl
/20/-
Nota
Seal 4K'
My commission expires
r,
Page 2 of 2