NCC242405_FRO Submitted_20240813

FI ANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, '/z acre or more inside a
c a u r, Ti 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, E 6L—.[[VV --�� 11VV11 ptcQl��c;iQn,�
(Please type or print)
Part A. J U L 1 7 2024
1. Project Name Madison Simmons
2. Location of land-disturbing activity: County Iredell City or Township ChamberSburg
HlghwaylStreetN Greenbriar Latitude 35.807632 Longitude -80.829042
3. Approximate date land-disturbing activity will commence: August 5, 2024
4. Purpose of development(residential,commercial, industrial,institutional,etc.):_Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 6.427
6. Amount of fee enclosed:$ 1925 . 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 Greg Duncan E-mail Address [e-mail]
Telephone [phone] Cell# 704-361-7717 Fax#
9. L downer(s)of Record(attach accompanied page to list additional owners):
@-1 I COI Al4fi U-C) 701—'to nSd6t
P Name
Telephone Fax Number
113 Bro ton Ln
Current Mailing Address Current Street Address
Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No.2924 Page No. 2240 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):
Maddison-Simmons Homes & Comm. gregamadisonsimmonshomes.com
Name E-mail Address
18825 W Catawba Ave, Suite 250
Current Mailing Address Current Street Address
Cornelius NC 28031
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 Corr: _i ' formation should there by any change in the information provided herein.
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Sign-tur.71.11. Date
I. VCAA tLIW Lhf f A,SkofI ,allotlalry Public of the County of kr�Cdt t I
State of North Carolina, hereby certify that L ccO LtY 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 3 day of �iA.n A4 ,20_a4 IAA_„„„..„..„,„,„
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