NCC242790_FRO Submitted_20240912

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR L D L I_L No person may initiate any land-disturbing activity on one or more acres, '/2 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&Development,Erosion Control Section.
(Please type or print.)
Part A.
1. Project Name 1260 N. Barkley Rd. Grading & Erosion Control Plan
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street N. Barkley Rd Latitude 35.7670 Longitude -80.8575
3. Approximate date land-disturbing activity will commence: ASAP
4. Purpose of development(residential,commercial,industrial,institutional, etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 4 Acres
6. Amount of fee enclosed:$ 1,100 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Billy Moose E-mail Address [e-mail]
Telephone N/A Cell# 704-902-1827 Fax# N/A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Billy Moose 704-902-1827 N/A
Name Telephone Fax Number
224 E Lackey Farm Rd 224 E Lackey Farm Rd
Current Mailing Address Current Street Address
Stony Point NC 28678 Stony Point NC 28678
City State Zip City State Zip
10. Deed Book No. 1028 Page No. 873 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):
Billy Moose [e-mail]
Name E-mail Address
224 E Lackey Farm Rd 224 E Lackey Farm Rd
Current Mailing Address Current Street Address
Stony Point NC 28678 Stony Point NC 28678
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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
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.
1u�>/ c - --
Type or print name Title or Authority
6,2 2
Signature ,� ) Date -��
Co 1t'AA ,a Notary Public of the County of St N`1 �' " '
State of North Carolina, hereby certify that `lam(_. y�UD 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,this \Z day of
ary
Seal 1- ) ) 4-f
My commission expires )-zAz:,
efc.Izry public State of Florida
John Ccttarman
vrnmisalon HH 3at537
llil '► �Ex�es i2nai2o2s
Page 2 of 2