NCC223329_FRO Submitted_20220922

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 Insurance Auto Auction
2. Location of land -disturbing activity: County City or Township City of Statesville
Highway/Street Business Park DrLatitude 35.748044 Longitude - 80 . 789106
3. Approximate date land -disturbing activity will commence: 11/26/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 54 . 0 AC
6. Amount of fee enclosed: $ 9,450.00 . 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 Dan Flamholz E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
0
Landowner(s) of Record (attach accompanied page to list additional owners):
GRP 1770 UNION AVE LLC+GRP
1780 UNION AVE LLC [phone]
Name Telephone
1212 York Rd, Ste C300
Current Mailing Address
Lutherville MD 21903
City State Zip
10. Deed Book No. 2 914 Page No. 2001
Part B.
Current Street Address
Fax Number
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):
GRP 1770 UNION AVE LLC+GRP
1780 UNION AVE LLC [e-mail]
Name
1212 York Rd, Ste C300
Current Mailing Address
Lutherville MD 21903
City State Zip
Telephone [phone]
E-mail Address
1212 York Rd, Ste C300
Current Street Address
Lutherville MD 21903
City State Zip
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
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
Zip
(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
Telephone
E-mail Address
Current Street Address
Zip 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.
Dan Flamholz
Type t name
S'tgna 9re
Principal
Title or Authority
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Date
I, 1�0_t k? Ma y f I L � � , a Notary Public of the County of a I I VM
State of North Carolina, hereby certify that pq Y1 F I A rn AO I Z _ 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 4l day of A ti U Off 20rr22
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