NCC221993_FRO Submitted_20220527

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity an one or more acres, '/a 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 North Charlotte Commerce Center
2. Location of land -disturbing activity: Countylugkffl_ City or Township Mooresvolle
Highway/Street Exrnore-Road Latitude 35-613253 Longitude -80,853967
3. Approximate date land -disturbing activity will commence: 6/i/2o22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 75
6. Amount of fee enclosed: $ 13,.i2s 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Marshall E-mail Address cmarshalliaevans-ac.com
Telephone Cell # 704-728-9784 - Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
B9 Exmore Road Owner, LP
Name cJo Blackstone Real Estate Advisors LP
345 Park Ave
Current Mailing Address
New YqdS NY 10154
city State Zip
404-852-2214
Telephone
345 Park Ave
Current Street Address
Fax Number
New York NY 10154
city State Zip
10. Deed Book No. Page No. — Provide a copy of the most current deed.
BK 2912 PG 2099 - 2102, BK 2912 PG 2103 - 2105, BK 2912 PG 2106 - 2110. BK 2912 PG 2111 - 2114
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):
F_Vans General Contraclots, L(--
Name
6101 Carnecie Boulevard -
Current Mailing Address
Charlotte NC 28209
city State Zip
Telephone 7Q4-728-qZ84
cmarshall(&evans-ac-com
E-mail Address
61 1 Carnania Boulevard
Current Street Address
Charlotte NC 28209
city State Zip
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;
U _4 ' I P-e,- � sJAj 4,
Name of Registered Agent' ff-mail AddilOiss
((a Q 14, , -N 4 LJt t S'k-2ce-)
Current Mailing Address Current Street Address
P-1 � I .-. t_�_ hJc_ 2 -?(, i �—
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 attomey-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.
Chad Marshall
Type or pdnt_rpn3e-,,
Sig
Vice Pr sodent
Title or Authority
S--.2-� -2f,—
Date
i, C"r L Fu I Lm— a Notary Public of the County Of., Ae-cr-11co 6tiva
State of North Carolina, hereby certify that C Pk� a
ppeared personally before me this day
and being duly swom acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this �; dayof 20 �. z
a'A(, I - 61 VVX_n
NoN6
Sea[
CARA L, FULTON
Notary Public, North Carolina
Mecklenburg County
myc Ornrn'ssiOn Expires
Jul 19, 2024
M I
My commission expires— �u 1q, 40z-4
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