NCC220622_FRO Submitted_20220203

Part A.
1. Project
FWANCIAL 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 sedimentatip��� submitted
and approved by the Iredell County Planning & Development, Erosi,7��r���! I S
(Please type or print.)
JAN 14 2022
2. Location of land -disturbing activity: County_aCLDC-- _ City or Township
Highway/Street 0eYGC1Je-Q. Latitude Longitude
3. Approximate date land -disturbing activity will commence: z 1 Z►o z Z _ - __�
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ; GS r OaWT742" ,
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): G
B. Amount of fee enclosed: $ . Sa , v . 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 a than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a fiat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name rG1'1 c� WCti� ev E-mail Address llr—e- JY I , I Cdr-
Telephone !J 9, Cell # _ QAX -b 9 7 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TYr_1.# 5�.Pl�t_ i.l A o -3d 9
Name f Te phone
_P, 6. &x 38-3
Current Mailing Address
jUppoesOutT
City state zip
Fax Number
271 ,B VSW &r# ,fin.
Current Street Address
city state 'Zip
10. Deed Book No. ZJ9 P, 3 Page No./8Q'/5'3 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
roc �'ia�P S�o�C�ot_�rCo►?si�.+Lin�r%/G�a� �.�vrw
Name E-mail Address
d - &-)X 3�3 3
Current Mailing Address
��V_iu.rr WG Z$ W7
City State Zip
Telephone
Z71 8E� PV1 90.
Current Street Address
1L[c K.Gsul w /Jtr ZS 117
City State Zip
Fax Number
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2. (a) If the Financially ResponsiL Party is not a resident of North Carolina, give ...sme and street address of the designated
North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zlp 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 information provided herein.
T e or print me Title or Authority
14176Z
ignature U I Vate
I, AC4Qrof l.�oe , a Notary Public of the County of_5�
State of North Carolina, hereby certify that _._ r o .[y ,.JAA / 44
appeared personally before me this day
and being duly sworn acknowledged that the above form wbs executed by him.
Witness my hand and notarial seal, this !!�iay of jo-n �T, 20 Z Z
a ��
ry -- -
Seal ����triirrrr�i
j��% �p A BD fi,� My commission expires _ /1foV' fig# ZQ 2{
�� VIP• ' tssion 0•f-
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