NCC221666_FRO Submitted_20220519

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/ 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 Project Barkley - Building 2
2. Location of land -disturbing activity: County Iredell City or Township Statesville
Highway/Street_E Barkley Rd Latitude 35.760647 Longitude-80.844579
3. Approximate date land -disturbing activity will commence: 6/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.0
6. Amount of fee enclosed: $ 3,500 . 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 Luke Bugenske
Telephone [phone] Cell #
E-mail Address Juke p�oak.engineering
Fax #f
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Williams Development Group, LLC
Name
331 High Street
Current Mailing Address
Winston-Salem, NC, 27101
City State Zip
336.529.6927
Telephone
331 High Street
Current Street Address
Fax Number
Winston-Salem, NC, 27101
City State Zip
10. Deed Book No. 2857 Page No. 1182 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):
Taylor Williams (Williams Development Group, LLC) [e-mail]
Name E-mail Address
331 High Street
Current Mailing Address
_Winston-Salem, NC, 27101
City State Zip
331 High Street
Current Street Address
Winston-Salem NC 27101
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Type or p�me Title or Authority
Signature path
1, � ' Xan t't"� , a Notary Public of the County of 6_N� _
State of North Carolina, hereby certify that Y1 -r. w ttm f5 ,-5;-r _ appeared personally before me this day
and being duly sworn acknowledged that the above was executed by him.
Witness my hand and notarial seal, this z7� day of 20
Notary
Seal
My commission expires 20;LcS
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