NCC231281_FRO Submitted_20230526

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR L D E L L No person may initiate any land-disturbing activity on one or more acres, Y2 acre or more inside a
r. i ra 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, ErosioRECEI ED
(Please type or print) v C v
Part A. NOV 0 3 2022
1. Project Name Southfork LLC - Lot 4
2. Location of land-disturbing activity County Iredell City or Township Mooresville
Highway/StreetBarley Park Lrlatitude Longitude
3. Approximate date land-disturbing activity will commence: 11-15-2022
4. Purpose of development(residential,commercial, industrial, institutional,etc.) COMMERCIAL
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) 2 .4 9
6. Amount of fee enclosed: $ 525 . 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$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name KG fqy Go cfl'7 E-mail Address K4 iL7 ( Acc/tarp-op-7r -
Telephone [phone],1 zf Cell# Fax#
9. Landowner(s) ,� ,Nof Record(attach accompanied page to list
additional owners)
5'okftirroitp nvriPi'/�! LLC / o41'5577-4o2/
Name Telephone Fax Number
Po /gax five a09S<o ,sC/k/wors/ Lathe
Current Mailing Address Current Street Address
Gorof/,'vs' Are_ 2863/ Corns/.wi /VC 2YO$/
City State Zip City State Zip
10. Deed Book No. 2334 Page No. 1837 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):
5o Aft Alro rrsw•/% LL L ka 74-,L, 90cf/c7 PYoce • Go,y
Name E-mail Address
Po /3ox //do a o y va /3r f,•/c✓crd Luse
Current Mailing Address Current Street Address
Grftf/-'4fr /1fL Z a'O3/ (_.pine/•'us Ale 21103/
City State Zip City State Zip
Telephone 7°`f- 51 1^9 0 Z / 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 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-mail Address
Current Mailing Address Current Street Address
City State 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 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
//G i vyA, Ga c/4! /ff 4 n Qos t r
Type
or print name Title or Authority
20 zz
Signature e Date
I, ROO 0\'1 U (1� 1 1 T1 S ,a Notary Public of the County of (1)
State of North Carolina, hereby certify that tw\*10\f\ �-,0 C\ appeared personally before me th s day
and being duly sworn acknowledged that the above form wad executed by(a.
Witness my hand and notarial seal, this d-[i day of L/CJ-4)(/1. , 20 0--)
Notary
Seal
My commission expires 0,;4.3,
RONALD N.TITUS
NOTARY PUBLIC
Mecklenburg County
North Carolina
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