NCC221131_FRO Submitted_20220322

FIN.,NCIAL RESPONSIBILITY/OWhcRSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, h acre or more Inside a
watershed, as covered by the Sedimentation Pollution Control Act the Iredell County Land
Development Code, before an acceptable erosion and sedimentation con a u
and approved by the Iredell County Planning & Development, Erosion Con i
(Please type or print.)
Part A. FES 2 2 207
1. Project Name h PS - Al l C 017 AnP6 m aw c ifl
2. Location of land -disturbing activity: County � 1 City or Township S7 Q te,s � i 11 C
HighwaylStreet-10f-P(ICCe1 DI` Latitude Longitude
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): )J)d 1.S&1(71
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .1. B
6. Amount of fee enclosed: $ -7 0 0 - 0 0 . 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. Was 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 knd rew kos'kedc, E-mail Address a k t qqq 2 Eg Q�na/,/, 0 OM
Telephone Cell # 704- 770:, ILI 0 _Far# 8) rell &0q6g CBZ
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KosbulI-f 1nYin �finents
Name
114 -nrad Iffen Z'q
Current Mailing Address
LLG 74 776 7a-10
Telephone
Aloorts vi it c 1V G z0115
City State Zip
erne
Current Street Address
Fax Number
City State Zip
10. Deed Book No. AZOv3 Page No. q,69- 9qi 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):
AndtcW Hostecic.i tOM
Name E-mail Address
114 Thad hjon M LPa-M e
Current Mailing Address Current Street Address
Mootavill o NG MI 15
City State Zip City State Zip
Telephone IN 110 /1,10 FmftmYtfl�r &02- 952 - g092
a0 CCU
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2. (a) If the Financially Responsible . _.ty is not a resident of North Carolina, give nam.- -nd street address of the designated
North Carolina Agent:
Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State
Telephone Fax Number.
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
E-mail 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.
A,24�2 6,11W.
Type or print name Title or Authority
*�'—ZZ—ZZ_
Signature T' Date
1� 6C41114, )r� hle2 a Notary Public of the
, County of '
State of North Carolina, hereby certify that �]d(rji) )6IF' ' appeared personally before me this day
and being duly swam acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of 2
Notary
Y HILDESRAND
MELQD Pt E" My commission expires
lyOTAfiY OAiTY
tREOELL CO 11OLINA
STATE OF t4ORTH CA
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