NCC230071_FRO Submitted_20230111

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, %: acre or more inside a
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 Statesville Sheetz Master Plan
2 Location of land -disturbing activity: County IREDELL City or Township Statesville
HighwaylStreet Old Mocksville Road Latitude 35' 49' 03" Longitude 801 49' 55"
3 Approximate date land -disturbing activity will commence: 08/2022
4 Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.59 acres
6. Amount of fee enclosed $ 700.00 . 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.
9.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dennis Terry E-mail Address [e-mail]
Telephone [phone] Cell # 704-202-8160 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners);
CAMPBELL A G+MARGIE C IRREVCC LIV TR
Name
Telephone Fax Number
CIO WILLIAM P POPE TRUSTEE P.O. BOX 1776
Same
Current Mailing Address
Current Street Address
Statesvi!ie N 28687
City State Zip
City State Zip
10. Deed Book No 67E Page No. 117
Provide a copy of the most current deed
Part B.
1. Person(s) or firm(s) who are finandally responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Selwyn Property Group, Inc.
[e-mail]
Name
E-mail Address
605 Lexington Ave., Suite 100
Same
Current Mailing Address
Current Street Address
Charlotte NC 28203
Same
City State Zip
City State Zip
Telephone [phone]
Fax Number
Page 1 of 2

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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Jon Phillips for Selwyn Property Group, Inc
Name of Registered Agent
605 Lexington Ave . Suite 100
Current Mailing Address
Charlotte NC 28203
City State Zip
Telephone [phone]
Jon &Selwyn PropertyG roup.com
E-mail Address
Same
Current Street Address
Same
Fax Number
State Zip
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
Type or pn ame Title or Authority
Si lure Date
f, Ut a Notary Public of the County of a v'�
State of North Carolina, hereby certify that T' D r\ t b 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 Iday of SUO_L1 20 ZZ
P An �� �4A_) W41A_/
No a
Seal r1Kj
Dg�'Z
My commission expires
,�,iNill t iii%"
�efTH Lys/4
�Ga0TAR�.s��
U�
. Win�8t.►G z •: i
i f • 0
flit{1
Page 2 of 2