NCC242514_FRO Submitted_20240816

DocuSign Envelope ID:6F1D62D5-C142-4966-B3E1-A86EDDCA7160
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR L L)L L L. No person may initiate any land-disturbing activity on one or more acres, 1/2 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.
(Please type or print)
Part A.
1. Project Name McDonald's
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Coddle Creek Highway Latitude 35.561001 Longitude -80.788885
3. Approximate date land-disturbing activity will commence: 09/02/2024
4. Purpose of development(residential,commercial,industrial,institutional, etc.): Commercial Restaurant
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.58 Acres
6. Amount of fee enclosed: $ 350 . 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 Alibia de Vente E-mail Address [e-mail]
Telephone [phone] Cell# 770-265-4006 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Cambridge Mooresville LLC 434-509-2145 N/A
Name Telephone Fax Number
831 E. Morehead Street, Suite 245 831 E. Morehead Street, Suite 245
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
10. Deed Book No. 2927 _Page No. 523-526 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):
McDonald's USA, LLC(Contact: Alibia de Vente) [e-mail]
Name E-mail Address
110 N. Carpenter St 110 N.Carpenter St
Current Mailing Address Current Street Address
Chicago, Illinois 60607 Chicago, Illinois 60607
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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DocuSign Envelope ID:6F1 D62D5-C142-4966-B3E1-A86EDDCA7160
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:
Corporation Services Company
Name E-mail Address
327 Hillsborough Street 327 Hillsborough Street
Current Mailing Address Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
Telephone [phone] 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 Register t E-mail Address
Current Mailing Address reet Address
City Zip City Zip
one 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.
Vivian Valdivia Development Officer
Type or print name Title or Authority
AAA,Ueleliuia•" 6/10/2024
U"'""'
Signature Date
•
I, (,-in c lTf V PA( ,a Notary Public of the County of Hi Il,SbcvDugh
State of North Carolina, hereby certify that VIVl a,{i '[CL taw q 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 I 0 day of ,2 Zq'
Notary
Seal
My commission expires 5/7/2-5
+��'; ••; 4INAT.OROELI
'*' i :*f MY COMMISSION#HH368885
'4. P� EXPIRES:May 7,2026
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