NCC215272_FRO Submitted_20210927

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
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 this form and an acceptable erosion
and sedimentation control plan have been submitted and approved by the Iredell County Development Services, Planning Division -
Erosion Control Section. (Please type or print.)
Part A.
1. Project Name Gambill Forest
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
HighwaylStreet Linwood Rd Latitude 35°58'32.79"N Longitude 80°78'36.20"W
3. Approximate date land -disturbing activity will commence: Currently Active
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 145
6. Amount of fee enclosed: $ already paid . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than .5 acre but < 1.0 acre
in a water supply watershed, a flat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been fled? Yes X No Enclosed
8_ Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Johnny Evans E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mark Henninger- Lennar Carolinas, LLC 704-759-6000
Name Telephone Fax Number
6701 Carmel Road, Suite 425 6701 Carmel Road, Suite 425
Current Mailing Address Current Street Address
Charlotte
City
10_ Deed Book No. 2562
Part B.
NC 28226 Charlotte NC 28226
State Zip City State Zip
Page No, 623-624 Provide a copy of the most current deed.
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):
Mark Henninger - Lennar Carolinas, LLC [e-mail]
Name E-mail Address
6701 Carmel Road, Suite 425
Current Mailing Address
Charlotte NC 28226
City State Zip
Telephone [phone]
6701 Carmel Road, Suite 425
Current Street Address
Charlotte NC 28226
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Mark Henninger Division President
Type �na Title or Authority
Signature Date
Z f e k l* C L 00) t" , a Notary Public of the County of GttC&
State of North Carolina, hereby certify that �lbL: � I_# i tii w 1 rY 6 i appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
l
Witness my hand and notarial seal, this (P"l day of l�( •'6�'U�ra , 20 C�
Seal rJtNfL[Ir�r''' Notary
•` ,-' �� .�¢�% My commission expires
c '• X/
ON
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