NCC230075_FRO Submitted_20230111

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, 36 acre or more inside :1
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 Powder Springs - Multi Lot Erosion Plan
2. Location of land -disturbing activity: County Iredell City or Township Troutman
Highway/Street Levi Lane Latitude 35.688549 Longitude -80.936691
3. Approximate date land -disturbing activity will commence: 518122
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.87
6. Amount of fee enclosed: $ 1,925.00 . Ana application fee of $175.00
pp per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a CIO -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 cf $100.00 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 Matthew Varney
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sills Springs Development
Name
PO Box 3965
Current Mailing Address
Mooresville NC 28117
City State Zip
[phone]
Telephone
236 Raceway Dr.
Current Street Address
Fax Number
Mooresville NC 28117
City State Zip
10. Deed Book No. 72 Page No. 108 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):
Nest Homes, LLC
Name
PO Box 3965
Current Mailing Address
Mooresville NC 28117
City State Zip
Telephone [phone]
mvarney@nesthomes.00m
E-mail Address
236 Raceway Dr.
Current Street Address
Mooresville NC 28117
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:
Nest Homes of the Carolina, LLC
Name
PO Box 3965
Current Mailing Address
Mooresville NC 28117
city State Zip
Telephone [phone]
[e-mail]
E-mail Address
236 Raceway Dr
Current Street Address
Mooresville NC 28117
City State Zip
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 Certlflcate 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 State
Telephone
E-mail Address
Current Street Address
City
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.
Matthew Varney
Type or print name
Signature
Manager
ritle or Authority
Date
I, r -,a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally before me this day
and being duly sworn acknowledged that the above form was execut& by him.
Witness my hand and notarial seal, this_[Lday of 20U
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