NCC242438_FRO Submitted_20240830

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
I )I .I_ I. 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 County Land
Development Code. before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning 8 Development, Erosion Control Section.
(Please type or pnnt)
Part A.
1 Project Name 11 AILAAVk 1411t( t 14d,1lts 11401 l C.,1.f o-
2. Location of land-disturbing activity' County (rat t City or Township
Highway/Street//A/431 AV gd Latitude 35.1 LI Longitude • 5(02- W
3 Approximate date land-disturbing activity will commence. 6115 I iq
4. Purpose of development(residential,commercial,industrial.institutional.etc.): C4^'tMt#440
v4
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .3
6. Amount of fee enclosed:Sit ,OZS . 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: 1.
Name Ka+ God t E-mail Address I #w1e 104 IIP*vlt*4,1.uM
Telephone ( Cell#1011 "I^ 711 -002/ Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
-11 Ayv i* 1411 l LLL - uL - 5Z? — goni
Name Telephone Fax Number
Zo 1140 woud Lahr
Current Mailing Address Current Street Address
(bv1^611.1.4s Nc. 2030
City State Zip City State Zip
10. Deed Book No.S 44- AZ I 1 dull Page No. 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):
11 As4,11,1 I-1-1 l LL L joduipropeerhi.Doti►
Name E-mail Arldrass
2o°l4o B41c1W114 L�ht
Current Mailing Address Current Street Address
Coyhd is Pk/ 263o/
City State Zip City State Zip
Telephone 101"4' S11 " qt7 2l
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 Zio
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.
Ka,'4.y,,, i4. -00//e,7 /i'llotwijc✓ , 77 44 ? /AV C
Type or print name Title or Authority
Signs re (J Date
I. VI1 ARff1 s• O v v ,a Notary Public of the County of M g Ck1tY0b kr
State of North Carolina, hereby certify that r yk Ao $..,
and being duly sworn acknowledged that the above form was`executed by him.
\ appeared personally before me this day
Witness my hand and notarial seal,this_"/$day of
Notary
Seal Karen H Jordan
' ' NOTARY PUBLIC My commission expires 4v%\ aval,
Mecklenburg County,NC
My Commission Expires August 18,2026
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