NCC223370_FRO Submitted_20220927

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Part A.
2
3.
4.
5.
6.
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/2 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.
Project Name Dollar General - Statesville
Location of land -disturbing activity: County Iredell
City or Township Statesville
Highway/Street Front Street Latitude 35.785413 Longitude-80.913770
Approximate date land -disturbing activity will commence: September 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.70 acres
Amount of fee enclosed: $ 350.00 . 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. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joe Strickland E-mail Address IstricklandCa-_)teramore.net
Telephone [phone]
Cell # 704-224-7364 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Teramore Development, LLC
Name
PO Box 6460
Current Mailing Address
Thomasville, GA 31758
City State Zip
10. Deed Book No. 2938
Part B.
Page No. 918
Telephone
165 Big Star Drive
Current Street Address
Fax Number
Thomasville GA 31758
City State Zip
Provide a copy of the most current deed.
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):
Teramore Development, LLC
Name
214 Klumac Road Suite 101
Current Mailing Address
Salisbury NC 28144
City State Zip
Telephone [phone]
istrickland(5)-teramore.net
E-mail Address
214 Klumac Road Suite 101
Current Street Address
Salisbury NC 28144
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:
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.
Joe Stricidand Agent
Type or nt nam Title or Authority
8--)f-o?ua2
Date
Q,4&Tr— L /C - 14 L/111 ?4AI a Notary Public of the County of
State of North Carolina, hereby certify that .50 C 7-/L-rC j< i.
and being duly sworn acknowledged that the above form was executed by him,
Witness my hand and notarial seal, this 2 3 Q � y of AUF U S r 21
DANIEL R. ALMAZAN
NOTARY PUBLIC
Rowan County, North Carolina
My Gommission Expires June 28,2027
/Z e w4 N
appeared personally before me this day
Z
Notavf- L/
My commission expires 3yN` se, Z 027
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