NCC221314_FRO Submitted_20220405

Part A.
2.
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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.)
Project Name Blue Gate Mooresville
Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Oates Road Latitude 35.59787 Longitude-80.85768
Approximate date land -disturbing activity will commence: 5/l/2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.00
Amount of fee enclosed: $1925 . 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.
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Neil Dyer E-mail Address neil0madisoncaoaroumcom
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Gate Mooresville Owner LLC
Name
6805 Morrison Blvd. Ste 250
Current Mailing Address
Charlotte NC 282
City State Zip
615-456-2984
Telephone Fax Number
6805 Morrison Blvd. Ste 250
Current Street Address
Charlotte NC 282
City State Zip
10. Deed Book No. 2880 Page No. 761 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):
Madison Capital Group Holdinas LLC
Name
6805 Morrison Blvd. Suite 250
Current Mailing Address
Charlotte NC 28211
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
Fax Number
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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:
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Name E-mail Address
Current Mailing Address Current Street Address
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City State Zip City State Zip
Telephone lG.4' ai,"U q 3? 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
Telephone 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.
A- f v 5
Type or pri nam
Signatur
V vQz.
Title or Authority
a -a q"a �-
Date
1, 11ne— L YALA, a Notary Public of the County of M&XW_6V✓C1
State of North Carolina, hereby certify that V 6L appeared personally before me this day
and being duly sworn acknowledged that the above form was e)Fecuted by him.
Witness my hand and notarial seal, this Z q day of rdOYVQALA, 20
Ji ZZ
6 AA
Notary
Seal _
My commission expires
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