NCC241862_FRO Submitted_20240703

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
0 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
2. Location of land-disturbing activity: County `Qerka(- City or Township (4X) 5V/L-la
Highway/Street j 5 Latitude 350 37'L5" 0 Longitude / ' 116 ' 37„
3. Approximate date land-disturbing activity will commence: 5044.UC")Z ZOZZi
4. Purpose of development(residential, commercial, industrial, institutional, etc.): 1/4005 Mi..
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): r/• Or
14
6. Amount of fee enclosed:$ 3325.00 . An application fee of$175.00�eerpacr�e(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$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed K
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ROL36WLr 1 L$S E-mail Address rpcat/e5 egion,504.coA,t
Telephone 7ou- GCS?Z- Z4'/ Cella Fax# N//9
9. Landowner(s)of Record(attach accompanied page to list additional owners):
LAJ I . :ontr3s !i, LIZ 70'1-' 7L- ZY//
Name Telephone Fax Number
1'2O 14)/46on PAgii ?a HQO 0/4-5Oyy P ,m R
Current Mailing Address Current Street Address
5T4i&vi144.-7 A/G ,25(4 5m7rsv«cc: !l/C :' ,7
City State Zip City State Zip
10. Deed Book No.222O Page No. 23 Z 7 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):
WILc ,'4*3S 2, LGG eLJilsonjr �9l16,114.10A cG.K
Name E-mail Address(,..)/L PfI4'50A) 7 D j'I D iJ Ic.3o4 P ALK T h
Current Mailing Address Current Street Address
3w SV/uE A/C 2 25"
City State Zip City State Zip
Telephone 7o'i '1I! 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:
1/4o,07,40 l,J/c.So,. , rR .ew;/Scanjr e c9/LOi(Acin.Co.K
Name of Registered Agent E-mail Address
1 O �J�c.soa Pke. 190 citc so.v PARA /
Current Mailing Address Current Street Address
—swu4= A/C 2 ,2 ST• R:svie.cc= A/C .2$-O 25-
City State Zip City State Zip
-
Telephone /64/— cs".1Z ' 241/l 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.
HOMO,5 /L-504) 3IZ RRCr„( Tc- L- Aor6AIT
Type or prin name Title or Authority
6 - 0 y
Signature Date
I. `-
',� ,� ' at ,a Notary Public of the County of cam[ntd.ivt
State of North Carolina, hereb certify that jjyjtrq CUI qbh ,1I . appeared personally before me this day
and being duly sworn acknowledged that the above form was executed y him.
Witness my hand and notarioiwtPartilten,. / day of /4NL, , 20 oiq
2 � •ssioq Co�', CA!
I G it L �C
o
;�c, o•y Notary
Seal c �� NoTARy a' r.
_ /
's PUBL1G ° My commission expires j /y 28
••'.• •
•.ry12.• .k'a``
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