NCC222519_FRO Submitted_20220713

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.)
Part A.
1. Project Name Oak Creek Subdivision
2. Location of land -disturbing activity: County Iredell city or Township Statesville
Highway/StreetOak Creek Road Latitude 35.7666 Longitude-80.7985
3. Approximate date land -disturbing activity will commence: May 24, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.). residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6
6. Amount of fee enclosed: $ . 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 X
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name Frank Kemo E-mail Address [e-mail]
Telephone [phone] Celllt 704-517-9108
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Helmsman Homes, LLC
Name
116 Gasoline Alley, Suite 105
Current Mailing Address
Mooresville NC
City State Zip
10. Deed Book No. Page
Part B.
980-500-1251
Telephone
Current Street Address
28117
Fax # [phone]
704-677-7666
Fax Number
City State Zip
Provide a copy of the most current deed.
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):
Landcrafters Sitework & Development, LLC
Name
256 Raceway Drive, Suite 1
Current Mailing Address
Mooresville NC 28117
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
Current Street Address
City State Zip
Fax Number
Pane 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 State
Telephone,
E-mail
Current Street Address
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
E-mail Address
Current Street Address
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.
pn&4-
Type or print name Title or Authority
Signature 0 Date
I, a Notary Public of the County of
State of North Carolina, he by certify that _ liW1 OaA 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 ( day of 20 99
tiG
Angela H King Notary
Notary
Gaston �l'
Nonh Caroiina9 My My commission expires [�''j 2a2,4' Commission Ex fires _T
pans 9 nf 9