NCC220617_FRO Submitted_20220210

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.
(Please type or print.)
Part A.
1. Project Name Preston Contractors, Inc.
2. Location of land -disturbing activity: County Iredell City or Township Bethany
Highway/Street James Farm Rd Latitude 35.82023 Longitude-80.871811
3. Approximate date land -disturbing activity will commence: September 8, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including oft -site borrow and waste areas); 5.42
6. Amount of fee enclosed: $ 1,050.00 . 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 tee 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 No Enclosed `'
8
t
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christopher M. Robertson E-mail Address [e-mail]
Telephone [phone] Cell # 304-288-7369 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Gulfstream West Investments, Inc. 304-329-2129
Name Telephone
15237 S Preston Hwy 15237 S Preston Hwy
Current Mailing Address
Kingswood
City
10. Deed Book No. 2728
Part B.
WV 26537
State Zip
Page No. 974
Fax Number
Current Street Address
Kingswood WV 26537
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):
Preston Contractors, Inc. [e-mail]
Name E-mail Address
3440 E Broad St 3440 E Broad St
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

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
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(b) If the Financiaily 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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 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.
Edward P. Boyle, II
rint name
nature
President
Title or Authority
August 28, 2020
Date
I, D E f' S C A G-0 O D a Notary Public of the County of
?(�_C S"C V rV
State of Wcs'tyi'U- ihereby certify that EDW1\2 7 r ISQ�1;6 ­0�_ 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 2 day of A 20 2 i
-„ V�Q
Notary
Seal
�G FICIALSEAL
NpTArzy PUBLIC
CM-y
A .TAIECF.VESTVIRGMA.'7ENISE A. Gopp
P.O. Box 157
n,WestVi,pinia z6444
(AmnL;:Ij n Expires June 27, 2021
"w"u'r*w.W'v YIy�
My commission expires uA �� Z—? k 202i
Page 2 of 2