NCC220554_FRO Submitted_20220131

11
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 LIPPARD SPRINGS SUBDIVISION - LOT 129, 313-132. 134-137 & 142
2. Location of land -disturbing activity: County IREDELL City or Township STATESVILLE
Highway/Street LIPPARD SPRINGS CIR. Latitude N35°43' 57.43" Longitude W80056'01.59"
3. Approximate date land -disturbing activity will commence: FALL 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): _RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.45 AC.
6. Amount of fee enclosed: $ 1,128.75 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 TIM GRISSINGER E-mail Address [e-mail]
Telephone, 919.577.1080 Cell # -- Fax # --
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BULLER RIVER DEVELOPMENTS 803.830.5459
Name
234 KINGSLEY PARK DRIVE, SUITE 110
Current Mailing Address
FORT MILL, SC 29715
City
10. Deed Book No. 2799
Part B.
State Zip
Page No. 2285
Fax Number
Current Street Address
City State Zip
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):
CORNERSTONE III PROPERTIES, LLC. [e-mail]
Name
234 KINGSLEY PARK DRIVE, SUITE 110
Current Mailing Address
FORT MILL, SC 29715
City
Telephone _ 704.577.4002
E-mail Address
Current Street Address
State Zip City State
Fax Number —
Zip
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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
Current Mailing Address
City State
Telephone --
E-mail Address
Current Street Address
Zip City
Fax Number --
State Zip
(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 istered Agent:
Name of Registered t E-mail Address
Current Mailing Address
City
Telephone --
Current Street Address
State 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.
Type or print name j� Title or Authority
Signature ❑at
-----------------------------
I, �M-Lj776�`jd'� , a Notary Public of the County of
� f
State of North Carolina, hereby certify that .Y W ' 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 �[ ' 20L
Notary
Seal In
My commission expires1_1 �]
FEMii1oastro-Martinez
ARY PUBLIC
ion County
rth Carolina
on Expires 11/02/2026
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