NCC223894_FRO Submitted_20221208

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 lredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the lredell County Planning & Development, Erosion Control Section.
(Please type or print)
Part A.
I. Project Name Shorewood
2. Location of land -disturbing activity: County. I redell City or Township Statesville
HighwaylStreet North Race St Latitude 35.7871 Longitude -80.8979
I Approximate date land -disturbing activity will commence: 12.20.22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
3.2 ac.
6. Amount of fee enclosed: $ 700 . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example; a 8.10-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 $100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Paul Penninger E-mail Address [e-mail]
Telephone [phone] cell # 704.996.6330 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Helmsman Homes, LLC 704.662.5500
Name
236 Raceway Dr., Suite #7
Current Mailing Address
Mooresville, NC 28117
City State
10. Deed Book No. 2889 Page
Part B.
Telephone Fax Number
236 Raceway Drive, Suite #7
Curren Street Add, ss
Mooresville, NC 28117
zp city
2220
State
Provide a copy of the most current deed.
Zip
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):
Helmsman Homes, LLC [e-mail]
Name
236 Raceway Dr., Suite #7
Current Mailing Address
Mooresville, NC 28117
City State Zip
Telephone [phone]
E-mail Address
236 Raceway Dr., Suite #7
Current Street Address
Mooresville, NC 28117
City
Fax Number
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State Zip

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:
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
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 cf the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address of the Registered Agent:
Todd Farlow
Name of Registered Agent
236 Raceway Dr. Suite #7
Current Mailing Address
Mooresville, NC 28117
city State zip
Telephone [phone]
[e-mail]
E-mail Address
236 Raceway Dr., Suite #7
Current Street Address
Mooresville, NC 28117
City State zip
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, is t, or registered agent with the authority to execute instruments for the Financially Responsible Person). I agree to
provi rrected it ,fcmation shoo Pere by any change in the information vided herei
Type print name Titijibr Authority
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Signature Date
I, ! S _ , a Notary Public of the County of
State of North Carolina, hereby certify that ��[i �?Qsi n V+t Q 1 e appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of X UTA. i 20 �a
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