NCC221918_FRO Submitted_20220711

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 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 Copper Pine Subdivision
2. Location of land -disturbing activity: County IredelI City or Township None
Highway/Street Copper Pine Ln Latitude Longitude
3. Approximate date land -disturbing activity will commence:
June 1st, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4-0
B. Amount of fee enclosed: $ �' I'. 60 . 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
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name i3e-%-\ L� r S/f er / E-mail Address bt✓, @fey CVl Q )10 CC. CaY►n
Telephone_ 1(/ 7 - jol - L/ J Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Je� AL
�'+r�ems,
Name Telephone Fax Number
19 G13 �-' /ill.„I Q &---4 5 r,
Current Mailing Address Current Street Address
re
i _r.ryid)us Xc �ro7 )
City /� / Stale ZIPCity State Zip
10. Deed Book No. 1 D) Page No. .1 � z 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):
're P ,"l ai 1
Name
q2 f S, M4A Sit -
Current Mailing Address p
1�wri�SGh AyC
City �} State Zip
Telephone / D/% q a / T
E-mail Address
3 4+.% CG
Current Street Address
City
Fax Number
State
Zip
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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;
Name E-mail Address
Current Mailing Address Current Street Address
City state Zip City
Telephone 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
E-mall Address
Current Mailing Address Current Street Address
City Stale 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.
of 14 &-n A el
Type or printnarn a Title or Authority
y1/z/z z
S natu Date
1, 0Gr _t , a Notary Public of the County of 4 —14"Ah
State of North Carolina, hereby certify that 7eM 9' G/ appeared personally before me this day
and being duly swom acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 2 day of 4df r , 200 29
L+/
PGWON WOODY Notary
NOTARY PUBLIC My commission expires
lredell County
North Carolina
My Commission Expires
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