HomeMy WebLinkAboutNCC233324_FRO Submitted_20231113 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
,1 EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, '/z acre or more inside a
a N T ,r N c 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 Herc Rental
2. Location of land-disturbing activity: County I_edell City or Township. Statesville
Highway/Street1470 Salisbury Hwy Latitude 35._76% __Longitude -80_.8556 _
3. Approximate date land-disturbing activity will commence: October 15.2023
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.50
6. Amount of fee enclosed: $ 525.00 . 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 Dominic Ferrovecchio E-mail Address dfspeed4@gmail.com
Telephone_917-731-4641 Cell# _ Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
1470 Salisbury Hwy, LLC 704-360-2874
Name Telephone Fax Number
117 Crosslake Park Drive 117 Crosslake Park Drive
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No._ 2891 Page No._458 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):
1470 Salisbury Hwy,LLC oldironmooresville@gmail.com
Name E-mail Address
117 Crosslake Park Drive 117 Crosslake Park Drive
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone__704-360-2874 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.
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Type or or' taa Title or Authority
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gna Date I '
I, C./-e--S S I. 0n ,a Notary Public of the County of PAC C,i .4
State of North Carolina, hereby certify that (�ti� tcl(O ti CIA.i C� appeared persona y before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this OHO day of t- 20 93
4111111111111bi . \c.%_ e..91----^-
Note f
`JESSICA CAIN My 'emmis expires 1����,
Notary Public, North Carolina - ' I
Mecklenburg County
My Commission Expires
May 23,2027
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