NCC240451_FRO Submitted_20240216

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, Y acre or more inside a
u rJ r c 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 Corvid PH2
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Langtree Campus Dr Latitude _ 35.5217 Longitude -80.8586
3. Approximate date land-disturbing activity will commence: Feb 28th, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 20.5 ac
6. Amount of fee enclosed: $ $3,675 . 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 V
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Doug West E-mail Address dwest@shelcollc_com
Telephone Cell# 864.423.2429 Fax#
9 Landowner(s)of Record(attach accompanied page to list additional owners):
Corvid Technologies, LLC 540.226.3938
Name Telephone Fax Number
153 Langtree Campus Dr. Ste 401 Same
Current Mailing Address Current Street Address
Mooresville, NC 28117 Same
City State Zip City State Zip
10. Deed Book No. 3009 Page No. 1624 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):
Corvid Technologies, LLC [e-mail]
Name E-mail Address
153 Langtree Campus Dr. Ste 401 Same
Current Mailing Address Current Street Address
Mooresville, NC 28117 Same
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
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.
Matt Hurley COO
Type or pr. �n/me_ Title or Authority
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Signature Date
I, e N YI �tl YLG A r IQV(aLu.t.l , a Notary Public of the County of I rid ete
• State of North Carolina, hereby certify that A Q 4+ --uv legappeared personally before me this day
and being duly sworn acknowledged that the above form was exeuted by him.
1 Witness my hand and notarial seal, this Ci day of jalet _G/4'1 , 20 2-1-1
Notary
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