NCC243464_FRO Submitted_20241107

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, '/4 acre or more inside a
c u u ri T v N Cwatershed, 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
Pinnacle Bank
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Williamson Rd. Latitude 35°35'14.9"N Longitude 80°52'27.0"W _
3. Approximate date land-disturbing activity will commence: October 2024
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.56 acres
6. Amount of fee enclosed:$ 550.00 . An application fee of$275.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $2475). 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Freeman E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Pinnacle Bank [phone]
Name Telephone Fax Number
150 3RD AVE S STE 900 same as mailing
Current Mailing Address Current Street Address
NASHVILLE, TN 37201
City State Zip City State Zip
10. Deed Book No. 2692 Page No. 1581 Provide a copy of the most current deed.
Part B. 2692 1584
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):
Pinnacle Bank [e-mail]
Name E-mail Address
1585 NORTH UNIVERSITY PARKWAY same as mailing
Current Mailing Address Current Street Address
HIGH POINT NC 27262
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:
National Registered Agents Inc
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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.
John Freeman Senior Vice President
Type or int name Title or Authority
ARM,-- November 5, 2024
Sign:tu • Date�(
I, A0. t . �6,Ae ,a Notary Publicr of the County of TDakl1 f1��Y1
State of North Carolina, hereby certify that � F(f_tr71Qf1 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 day of Nb JU,nII . 11
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