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HomeMy WebLinkAboutNCC220912_FRO Submitted_20220225FINANCIAL RESPONSIBILITY/OWNERSHIP FORM EROSION & SEDIMENTATION CONTROL No person may initiate any land -disturbing activity on one or more acres, 1/2 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_. V-t-ur � wvU 604 yl V 2. Location of land -disturbing activity: County rL ! City or Township V+ti oo rt ✓y' Highway/Street ' e- ` k�, r': Latitude Longitude 3. Approximate date land -disturbing activity will commence: ` k ✓ r6 c < awn •. Z 5 Z A/' 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Y4 Q S to J!ti 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Sr a- rt 5 6. Amount of fee enclosed: $ V75, 00 . An application fee of $175.00 per acre (roundod up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than .5 acre but < 1.0 acre in a water supply watershed, a flat foe of $135.00 is assessed. 7. Has an erosion and sediment control plan been filed? Yes V No Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: ��i Name l�""`�t a`"C0n E-mail Address C LI- 4 6 C re 0&AC 5 , 60-L Telephone 9 23-79 Z 7 b33 Cell # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Fax # I — Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. Page No. Provide a copy of the most current deed. Part 13. 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): (..I'a f nnc'Al 6 cre5•Aic-at s . co04 Name E-mail Address j vq �, F P r y1 w oo C/� Current Mailing Address tMoo,,ow'Ue I`I C< City State zip Current Street Address city Telephone Fax Number. State Page 1 of 2 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 Telephone E-mail Address Current Street Address State 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 Registered Agent: Name of Registered Agent Current Mailing Address City Telephone E-mail Address 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 provi e corrected information should there by any change in the information provided herein. �41 {mac © /i '6441,6L reor print n Title or Authority 7- Z3 19 ure date I, C h� \S \ Q , a Notary Public of the County of �Uyn ex State of North Carolina, hereby certify that C_�(Nagr\' "S:)O_Cor1 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 `Job. day of u/`�R— 20� n ^ i` � 1wd�Q � l.►..�1L�� Notary Seal CHRISTIE BUTLER NOTARY PUBLIC ALEXANDER COUNTY, N t l My canmiulon Irea 0 i My commission expires Y C\S1 d4�V\ Page 2 of 2