NCC242900_FRO Submitted_20240919

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres, '/z acre or more inside a
r, P• C I; 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 Pirates Cove Lots 1-4
2. Location of land-disturbing activity: County Iredell City or Township_
Highway/Street Blackbeard Ln. _Latitude N 35.372362 Longitude W 80.525304
3. Approximate date land-disturbing activity will commence: August 15, 2024
4. Purpose of development(residential,commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.89 ac
6. Amount of fee enclosed: $ 550.00 . 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 Mark Benitez E-mail Address mbenitez©peachtreeres.com
Telephone Cell# 704-928-9215 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Peachtree Residential NC LLC 770-622-2522
Name Telephone Fax Number
7380 McGinnis Ferry Rd 7380 McGinnis Ferry Rd
Current Mailing Address Current Street Address
Suwannee, GA 30024 Suwannee, GA 30024 _
City State Zip City State Zip
10. Deed Book No. 3063 Page No. 955 _ Provide a copy of the most current deed.
DB 3063 PG 1348
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):
Peachtree Residential-c/o David Borreson [e-mail]
Name E-mail Address
7380 McGinnis Ferry Rd 7380 McGinnis Ferry Rd
Current Mailing Address Current Street Address
Suwannee, GA 30024 Suwannee, GA 30024
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:
Dave Borreson [e-mail]
E-mail Address
_132 Joe Knox Ave Ste 100K 132 Joe Knox Ave Ste 100K
Current Mailing Address Current Street Address
-Mooresville, NC 28117 Mooresville, NC 28117
City State Zip City State Zip
Telephone [phone] 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 foram
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 rxorrected information should there by any change in the information provided herein.
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Type or pint name / Title( Authority
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Signatu Date
I, n A + C�4 : w° c� e.l, > o 4'1 , a Notary Public of the County of 13 G ry o' I
State of Georgia, hereby certify that 1)G v i c II 8 n v v L s o K...J 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 �, day of U I 20 4
„"` VE,47-,"/.,,, Notary
-Z' kTr. •` R), - r My commission expires r� ��' ° G
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