NCC240105_FRO Submitted_20240117

rP FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
i�
EROSION & SEDIMENTATION CONTROL
IR[D E L 1`� No person may initiate any land-disturbing activity on one or more acres, % acre or more inside a
u watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sediment n s been submitted
and approved by the Iredell County Planning&Development, Ern erei oI S etl �
(Please type or print.)
Part A. DEC 19 AM
1. Project Name Peyton's Creek Subdivision
2. Location of land-disturbing activity: County Ircdcll City or Township Fallstown
Highway/Street Laurel Cove Rd Latitude 35.697851 Longitude -80.970100
3. Approximate date land-disturbing activity will commence: November 20,2023
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 21.25
6. Amount of fee enclosed:$ 3,850 . 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 Brad Robison E-mail Address brobison@a rci-cs.com
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Lake Life Properties,LLC 704-796-6593
Name Telephone Fax Number
1315 Graham Woods Dr
Current Mailing Address Current Street Address
Mt Ulla,NC 28125
City State Zip City State Zip
10. Deed Book No. 3007 Page No. 1992 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):
Lake Life Properties,LLC [e-mail]
rci-es.com
Name E-mail Address
1315 Graham Woods Dr
Current Mailing Address Current Street Address
Mt Ulla,NC 28125
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:
Lauren Robison Irobison(rci-cs.com
Name of Registered Agent E-mail Address
1315 Graham Woods Dr
Current Mailing Address Current Street Address
MI Ulla,NC 28I25
City State Zip City State Zip
Telephone 2�296 b593 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.
Lauren Robison Owner
rT r print name Title or Authority
1WjWL C I2151�7,3
ig ature "— Date
1)I, �i 04 f)'d ,a Notary Public of the County of ecid
State of North Carolina, hereby certify that I l'1 Li fen C �tl� n 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 l day of 15(tiff-
Notary
,20,-!
Seal My commission expires L -0?02,5
MELODY HILDEBRAND
NOTARY PUBLIC
IREDELL COUNTY
STATE OF NORTH CAROLINA
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