NCC215644_FRO Submitted_20211012

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, 'A acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredeli 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 prinL)
Part A.
1. ProjectName DIDIO CIRCLE SUBDIVISION
2. Location of land -disturbing activity; County IREDELLCity or Township
Highway/Street DIDIO CIR Latitude Longitude
3. Approximate dale land -disturbing activity Wit commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
RESIDENTIAL
2.43 AC
6. Amount of fee enclosed: $ 525 . 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__"_
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
T''7� 1 -01 n �.S�o�S
N-.me Dow t S F-mail Address V
Telephone ? Zell w . ___ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
A. t st &0'rzk's
'mv _.
.2621 C4-44c-
Current h9aiiing Address
City State Zip
1elephune Fax Number
. 2 0?--7-
Current Street A¢d ress
Nwus - NC- ill —
City State Zip
10. Deed Book No. �S �� Page No. yqD.._ _. Provide a oopy 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 ail
responsible parties on an attached sheet):
AA4 Comoww Aotl
Name
'Po_ 3U*
Current Mailin Address
City -r staattef Zip
Telephone,
, �.5 &IZ�S tawt�S C�r�-I
E-mail Address
Current Street Ad r ss
City istate Zip
Fax Number
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(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
addre o(f]the�j gistered t:
Name of Registered Agent E-mail Ad ess
y�)t � f_5� 7 6 Aru -39cs
Current M MdresdJCurrente#'Address
1g fl ]
City State Zip City State Zip
Telephone 0 YU Fax Number -2 7AM --
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 netted information should there by any change in the information provided herein.
t`'
e T or print name !! Title or A o� dty
_ � /` R(
Signature Dal
a Notary Publics of the County of
State of North Carolina, hereby certify that Ee;g�_ / ' 4')*°g V, 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 / 0 G L C '
Notary
Seal
My commission expires"
E16NINA DUBOIS ;RAY
Public, North Carolina
cklenburg County
mission Ex� s
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