NCC221322_FRO Submitted_20220405

Part A.
FlI ,ANCIAL RESPONSIBILITYIOI�►14ERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/2 acre or more inside a
watershed, as covered by the Sedimentation Pollution CaWAn
d r�7,ty Land
Development Code, before an acceptable erosion and sedime ubmitted
and approved by the Iredell County Planning & Development, E sr Ito .
(Please type or print.)
MAR 07 2022
1. Project Name % 1� r% Ij,411707 /
2. Location of land -disturbing activity: County 1� li t� ✓< City or TownshipG_ A
Highway/Street r� A M l L T 1U Latitude Longitude
3. Approximate date land -disturbing activity will commence: _ "' �2 -2 ozi— I 1
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ke_�51J
5. Total acreage disturbed or uncovered (Including off -site borrow and waste areas): �' 3
,, o
B. Amount of fee enclosed: $ �1 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
6. Person to contact should erosion and sediment control issues arise duringt land -disturbing activity:
Name r �t ^A7 E-mail Address '+1 G r✓ 62
Telephone L " `�" �•� J�k Ceti # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
e::��
1f CV/1.
Namefl
�
!�
227 3 1�114 3-7s-=-
Fax Number
4'(
Telephone j
4 " e,
Current Mailing Address
City
S ate Zip
Current 5treer AUUi dw
Zip
City State
10. Deed Book No.
Page No. (o
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): ++
A a(rc7 ,.9.a 5 b r (r1zGGd
Name E-mail Address
4 , +�,veif
Current Mailing Address
City State Zip City State Zip
Telephone % 2 `f -7'/�/ -3 Fax Number
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2. (a) If the Financially ResponsibleCrty is not a resident of North Carolina, give ri;, -- and street address of the designated
North Carolina Agent:
m 4 /e y J 6?,R o 6ow
Name
j E-mail Address
urrent Mailing Address Current Street Address _f
V1. //" /& . z 1,117 A)e- -
City / State Zip City State Zip
Telephone 70 Y' 5`L7Z- 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 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
provide7�1A
ected inft�rmati h&"gWAany change in the information provided herein.
"W n ajo 1'J-2N0, n.
Type or print name Title or Authority
�'- -1,— 3 - ;7q Q'L
bate
Notary Public of the County of
State of North Carolina, hereby certify that L/ iL , r� l � r -S P MMO)
and being duly swom acknowledged that the above form was qxecuted by him.
Witness my hand and notarial seal, this Jay dY- 20
Seal
F
nwealth of Pennsylvania - NotheSeal
eatherJohnson.Notan.-
Washington C,
commission expires Al:-- .422
Commission number 1223455
Commonwealth of Pennsylvania - Notary Seal
Heath-r.lohr•son, Notary Public
r-nCounty
MyC„'ll;d',',tCrr expires April8, 2022
C:),njr,.ssion number 1223455
My commission
personally before me this day
�ao��
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