NCC233385_FRO Submitted_20231114

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
: . EROSION & SEDIMENTATION CONTROL
No person may initiate any land-disturbing activity on one or more acres, 'A acre or more inside a
v 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 Life Storage-Shearers Road
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Rocky River Rd. Latitude 35.534068 deg. Longitude -80.798475 deg.
3. Approximate date land-disturbing activity will commence: 10/26/2023
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.60 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 9-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$135.00 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 Jamie Rolewicz E-mail Address [e-mail]
Telephone [phone] Cell# 704-905-0335 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Legacy Pointe Rocky River, LLC 704-905-0335
Name Telephone Fax Number
19354 Watermark Drive.Suite 102 19354 Watermark Drive.Suite 102
Current Mailing Address Current Street Address
Cornelius NC 28031 Cornelius NC 28031
City State Zip City State Zip
10. Deed Book No. 3004 Page No. 732-734 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):
Legacy Pointe Rocky River, LLC [e-mail]
Name E-mail Address
19354 Watermark Drive.Suite 102 19354 Watermark Drive.Suite 102
Current Mailing Address Current Street Address
Cornelius
NC 28031 Cornelius NC 28031
City State Zip City State Zip
Telephone [phone] 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:
Laura Temple [e-mail]
Name of Registered Agent E-mail Address
19354 Watermark Drive.Suite 102 19354 Watermark Drive.Suite 102
Current Mailing Address Current Street Address
Cornelius NC 28031 Cornelius NC 28031
City State Zip City State Zip
Telephone [phone] 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.
Jamie Rolewicz 11Vt6t
'se or pnn ' Title or Authority
1111111 AID 0+. 7_ - 2<0 23
Signature Date
I, L/ (JlV(n (2(41`tl , a Notary Public of the County of I yob-!I
State of North Carolina, hereby certify thatatak ril. k LC•- 44,41 Vt. 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 0144 A • 2-3
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