NCC230522_FRO Submitted_20230224

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No peTsrDn may inifiate any Land -disturbing activity on a or more ems, A acre or more inside a
watershed., as covered by the mentabor: PoHuiion Gong Art and the trade][ County Land
Development Code, befbre an a=eptabke et on and irr l;� control p€an has been sutmitted
2ind approved by ibe trede l GGunty Planning & DevelopmeErosionControl Sew.
(Plea type or print)
Part A,
Project: Kane Goddard School x Mooresville
2. Location of land-f t rW activity: ours redelI
ly or To nip ooresi11e
fthwayiSreet Murray Lane latlw� 3 3' . N ionqitud84d V32 'W
3. Approximate date lar�i-t Mufbing actity wilt corn mangy: Ober 2022
4_ Purpase ofdevelopment lr id�rii�t, commercial. industrial, insfit dal, e-t Daycare aisl1[
TcdW acreage disturbed or uncovered (including off-,5ft bwow aqd waste areas): �2.41 acres
B_ Amount of fee enclosed, 52U0 An appOlIcation fee of 175.O per a (rounded to the rwd acre) is
assessed without a ceiling amount (Example: a 8-10-acre appricatibin fee is $1 5), For pr ects > than 0.5 aves but no
p ater than 0-99 acres in a water 5uppty watershed, a fiat fee of i i0-00 is ssed.
7, Kaz an ar is and sediment control plan been filed Yes lac �r�c
8. Porgy to contact should erosion and sediment control issues arise during lard -disturbing a.ctiwity:
Name David Buis -mail Address [e-mail]
farrara-duist.l
Telephone 80 W 2-4348 cell 4 954-214-2 Fax # 8 2 0
9. Landowner(s) of Record (adach actorn.panpagato Fist additional owners):
Thomas and KaNeen Dotoli
Marne Taleone Fax Number
156 Sea Trait Drive 111 Murray Lane
Current Mailing Address Current StFest Address
Mooresville NC 28117Mooresville N C 28117
city state Zip Cif Ito Zip
10. Deeo&. No, 928 Pane Rio_ 216 PrWide a oopy of the most current deed_
Part B.
t, Persc€ s) orfirm(s) who are financially revonsibfo far tW land -disturbing actiivft 1:wife a cornprehermive list of all
responsible paites on an attach sheet =
MacRae -Bryan Holdings, , 1
Name
1Town Square Circle
Current Mailing Address
Mooresville NC 28117
4 ate Zp
Telephone[phone]
Mooreavl1leNC o ddardschools.coin
E-mail dress
9 Bayberry Creep Circle
Current Streat Address
Mooresville N '117
... sty zip
Fax Number
Page I of

Lan,dowr r s of Record (attach ar mpanied page to list additional ers)
Robin M Bailey
Nam
11738 Dan Maples Drive
Current Wiling Address
Telephone Fax Number
07 Murray Lane
Current Shaet Address �.
Charles
NC
28277
Mooresville 17
city
State
Zip
Cam. stag ... zip
Deed Sook No,
2-571
Page tq,2.
609Prav a mpy of the most current dL---d.
Landover (s) of Rewrd (attach accompanied page to fast wWi6onaf Owners).
Robin M Bailey
Fare
11738 Dan Maples E ve
Current Mailing Address
Charlotte NG 28277
my ate ZP
Telephone 1= Number .. ..
105 Murray Lane
Current Street Address
Mooresville N 811
- state , P-
Dead look No. 71 Page No. 609 PmWda a copy of the mst current deed.

. [ t it as liy as i. le Party is not a resident of North Carolina, give name and street address of the demoted
Now Catalina Aft:
Name
Current failing Address
city state zip
Tell
E-mail Address
Current Sbzet Address
IV—state�@ iR
Fax Number
(b} If the Financially Respamsbe Party is a Partnership or affuit Person ending in business infer an mimed name, arch
a copy of the Certificate of Assumqd karma_ If the Flnaincially ResponsbW Party is a Corporation, give name and street
address of the RegIstered fit,
Barbra Bryan (President)
Name of Reglstsred Agent
179 Town Square Circle
Current Bailing Address
Mooresville 81
City Staie Zip
Tefh 7[-06
MooreavilleN
-nail Ac1dress
279 BaybegyCreek Girde
Current Sveet Addres9
Mooresville N
city state . 20
Fax Number
The above infarmatian Is trix andcon-ad to the test of my knowledge and Wkef End was provided by roe ender nh, 0 riis form
roust be sigma by the Finandany Re5ponsible Person if an individual or his attorney -in -fact, or it not an Individual, by are fi r,
director, partner, or mgistered aft with Um au city to emote lnstrurnewts for the RnanNially Respons.Ue Peron. I agree to
pravIde corrected Informal should Mere by any chanp in the inforrnat:Rm provided heron.
Type print name
?I xz"�
rrt�
Tie or Authority
Date
a Notary Public Of the County of _ ank
State rrf NoM Carolina, ttareby aartily that -Bark?rqBk-41ZP7 appears personally before me this day
and being cite sworn a cnoWeded that the abow fora was exec b�,
ass my hand and notarial seal, this day Of
Nary
Seal' My Commission expires 17-26
tl ON
NRMY PbljfC
North CarcAna
Y CW(rffS&IW Expires J* n 2M
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