NCC215265_FRO Submitted_20210927

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
• No person may initiate any land -disturbing activity on one or more acres, Y2 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 Proposed Commercial Center - Williamson Road at Joe Knox Ave
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Williamson Road Latitude 35 35'28" N Longitude 80 52'17' VV
3. Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2-98 acres
6. Amount of fee enclosed: $ s i 00 . 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 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $135.00 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 T. Martin Fridy E-mail Address tmfC&,magnoliapropertygroup.com
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harold D. Knight Revocable Trust
Name Telephone Fax Number
686 Isle of Pines Rd
Current Mailing Address
Mooresville NC
City State
10. Deed Book No. 16E
PB 66
Part B. "
28117
Zip
Current Street Address
City
State
Page No. 466 Provide a copy of the most current deed.
Page No 114
Zip
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):
MPG Arden, L
Name
31 Wade Hampton Blvd.
Current Mailing Address
Greenville SC 29B09
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
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:
CT Corporation System
Name
160 Mine Lake Ct. Suite 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephon
E-mail Address
Current Street Address
City State Zip
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.
L7 /f-kltn"
Type or print na Title or Authority
17-o
Signature ate
I. /V %) Nan .� :L /Fp ES _. a Notary Public of the County of Gajzcm L,I LLt
State of North Carolina, hereby certify that Vr 0 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 r?l day of 20�_
Notary `
Seal
My commission expires
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