NCC220264_FRO Submitted_20220113

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 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 ra�'� F�Irs
� Pro JPerY'j
2. Location of land-disturiaing activity: County�e dr e
/ Qp / f� City or Township �f'D�q M n y�
Highway/Street SIrX tYGr� Y�. Latitude L4 l;ZZ
r� IL Longitude
3. Approximate date land -disturbing activity will commence: % eG 349
4. Purpose of development (residential, commercial, industrial, frislitufional, etc. :
5. Total acreage disturbed or uncovered (including off sife b ) �P$ a
0 0 borrow and waste areas):
Amount of fee enclosed: $ 35a
assessed without a calling amount (Example: a 9-acre aAn pplicaon tion nn tee f $
75-00$1575per
acre (rounded
d up to the next acre) is
greater than a,99 acres in a water supply watershed, a fiat fee of $135.(70 is assessed. projects than ti.5 acres but no
7• Has an erosion and sediment control plan been filed? Yes
No�Enclosed
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
_ E-mail Address
Telephone t - Orj - 91S0
Cell #
Q
10.
Fax #
Landawner(s) of Record (attach accompanied page to list additional owners):
parr C� Di�� �+� '�y
Name
Telephone
Curren( Maili ddress
r�orLs vj� 0c 9//
State
City p
Zip
Current Street Address
Deed Book No. Zip
Part B.
Ptate age No. Provide a copy of the most current deed.
Fax Number
7. Person(s) or firm(S) who are financially responsible for the land -disturbing activity (provide a comprehensiv l'
responsible parties on an attached sheet):
I�r�t
Name
Current Mailin Address
a0�V)%1 l
City
State zip
Telephone 90
dr, a4 ,e st of all
E-mail Address
Current Street Address
City State
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
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 form
must be signed by the Financially Responsible Person if an individual or his attomey-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 info ation provided herein.
L G r e,- r �, n cfrr er
Typo or #Hnt name Ti le or Authority
�" � C .2-z
5ignatu Date
Notary Public of the County of
A elc*_ Iex_1 bu a�
arouadd being duly sworn nacknowled accartknowledged that the aby thatove was exec to �hi
g executed by him.
Witness my hand and notarial seal, this _day of U a rt , 2Q 2 2
Seal Notary
appeared personally before me this day
My commission expires DI -~� � �j
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