NCC241315_FRO Submitted_20240506

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR C U E L 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 Control Act and the Iredell Coun�+ Land
Development Code, before an acceptable erosion and sedimenta jai �•n' .' .I• , =�be subTrtitted
and approved by the Iredell County Planning&Development, Eros,•n L.
(Please type or print)
Part A. MAR 2 7 2024
Project Name
Langtrcc Manor,LLC
1
2 Location of land-disturbing activity County In ilea City or Townships. . Davidson
Highway/Street Langtree Rd Latitude 35.524725 Longitude -80.882637
3. Approximate date land-disturbing activity will commence: April 2024
4 Purpose of development(residential,commercial, industrial,institutional, etc.)- residential
5 Total acreage disturbed or uncovered(including off-site borrow and waste areas) 7.896
6. Amount of fee enclosed $ 1400 . An application fee of$175 00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575) For projects > than 0 5 acres but no
greater than 0 99 acres in a water supply watershed, a fiat fee of$135.00 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 Brian McManus E-mail Address [e-mail]
Telephone 704-746—i7o9 Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners)
Langtree Manor,LLC 260-414-4448
Name Telephone Fax Number
662 Langtree Rd 662 Longtime Rd
Current Mailing Address Current Street Address
Mooresville,NC 28117 Mooresville,NC 28117
City State Zip City State Zip
10. Deed Book No 2896 Page No. 282 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)
Langtrce Manor,LLC [e-mail]
Name E-mail Address
662 Langtree Manor,LLC 662 Langircc Rd
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.
Steve Bermes Manager
Type or print name Title or Authority
03/24/2024
Signature Date
I, ‘ �(Q' C. n‘C, , a Notary Public of the County of R1,rc1 +2tn‘Duy3
State of North Carolina, hereby certify that s_rQ qec) (me S 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,this25 day of �Q 1CY) , 20 a,y
011/2A
Notary U
Seal
My commission expires /0/0VcW6078-
Christy Knlgtits Palmer
r- NOTARY PUBLIC
Mecklenburg County
North Carolina\
My Commission Expires 10/2/2028
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