NCC242978_FRO Submitted_20240925

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELLi No person may initiate any land-disturbing activity on one or more acres, '/z acre or more inside a
COUNTY • N 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 Animal Hospital on South Main
2. Location of land-disturbing activity: County Iredell City or Township Troutman
Highway/Street Brittany Place Latitude 35.684767 Longitude -80.863261
3. Approximate date land-disturbing activity will commence: FALL 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.21 Acres
6. Amount of fee enclosed: $ $550 . 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 Ben Loftis E-mail Address [e-mail]
Telephone [phone] ext 242 Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Cooney Properties, LLC 704-802-1280
Name Telephone Fax Number
181 Mocksville Highway 181 Mocksville Highway
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. 3061 Page No.2298 Provide a copy of the most current deed.
P/O DBK 2888 PG 951
Part B. P/O PBK 75 PG 128
P/O PBK 81 PG 73
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):
Cooney Properties, LLC [e-mail]
Name E-mail Address
181 Mocksville Highway 181 Mocksville Highway
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
Telephone7O4-802-1280 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:
Joseph C. Cooney [e-mail]
Name of Registered Agent E-mail Address
181 Mocksville Highway 206 Winding Brook Way
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
Telephone [phone] 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.
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State of North Carolina, hereby certify that \JD6. e appeared personally before me this day
and being duly sworn acknowledged that the above form was executed him.
Witness my hand and notarial seal,this Z2 day of A- , 20 -T
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