NCC242521_FRO Submitted_20240819

• FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres, 'h acre or more inside a
c o u N r v 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 Pond View Ridge
2 Location of land-disturbing activity County Iredell City or Township Barringer
Highway/Street Pond View Road Latitude 35.6341 Longitude-80.8063
3. Approximate date land-disturbing activity will commence. August 2024
4 Purpose of development(residential, commercial. industrial, institutional. etc ) RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.0
6. Amount of fee enclosed. $ $200 Modification . An application fee of$275.00 per acre(rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $2475). 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Paul Carter, PE E-mail Address pcartertnyahoo.com
Telephone [phone] Cell# 865-816-4557 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Diane Oliveira / BAROL 19D. LLC 973-787-7461 973-858-0279
Name Telephone Fax Number
105 Barrister Bay Lane 105 Barrister Bay Lane
Current Mailing Address Current Street Address
Mooresville, NC 28117 Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No. 1929 Page No. 1932 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):
BAROL 19D. LLC [e-mail]
Name E-mail Address
105 Barrister Bay Lane 105 Barrister Bay Lane
Current Mailing Address Current Street Address
Mooresville. NC 28117 Mooresville,NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number 973-858-0279
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
3)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
—Dl ao-e_ d Il t-e /rG I fcna �/rlem ixr
T e or print n Ti e or Authority
/31/ 1071
nature Date
I, '' �e.rw_ &o� • IN a Notary Public of the County of -I. c��ct11
State of North Carolina, hereby certify that U a,ci,� d! , VC,I r C._ 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 (SF� A
day of ,A. .,s 20 a 41
Notary
Seal 6 / ' /,L My commission expires (/
SER E N,q '',
:.. �: .
,
= m
0�`.: _3L
Page 2 of 2