NCC231143_FRO Submitted_20230426

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
(t) EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, % acre or more inside a
c o r v r. . 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.
North Fork Business Park
1. Project Name
2. Location of land-disturbing activity: County Iredell City or Township Troutman
Highway/Street Murdock Rd Latitude 35 .720100 Longitude —8 0 .8 814 7 0
3. Approximate date land-disturbing activity will commence: April 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial/Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 43 .53
6. Amount of fee enclosed: $ 7700 . 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 Butch Bouwens Email Address [e-mail]
Telephone Cell# 704-363-8707 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
North Fork Investments, LLC 704-363-8707
Name Telephone Fax Number
164 Nugget Lane 164 Nugget Lane
Current Mailing Address Current Street Address
Troutman, NC 28166 Troutman, NC 28166
City State Zip City State Zip
10. Deed Book No. 2930 Page No. 1081 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):
North Fork Investments, LLC [e-mail]
Name E-mail Address
164 Nugget Lane 164 Nugget Lane
Current Mailing Address Current Street Address
Troutman, NC 28166 Troutman, NC 28166
City State Zip City State Zip
Telephone [phone] Fax Number 70 V �4`7� /y0
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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 p nt name Title or Authority
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I, L.+✓t/Gi; [_ Rem , a Notary Public of the County of /v{04
State of North Carolina, hereby certify that 1C011, l3DCI.LcleA5 Jr . 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 6el�day of Fa-Yu ' , 20 3
"A�L Notary
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