NCC223539_FRO Submitted_20221014

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 T. J. Systems Properties, LLC
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Location of land -disturbing activity: County Iredell CityorTownship Concord
Highway/Street Marble Road Latitude 35.801655 Longitude-80.948344
Approximate date land -disturbing activity will commence: November 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .53
Amount of fee enclosed: $ 350.00 . 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.
Has an erosion and sediment control plan been filed? Yes No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tim Johnson
Telephone [phone]
E-mail Address [e-mail]
Cell # 704-880-0718 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
T. J. Systems Properties, LLC 704-880-0718
Name Telephone
269 Marble Road
Current Mailing Address Current Street Address
Statesville, NC 28625
City State
10. Deed Book No. 2321
Part B.
Fax Number
Zip City State Zip
Page No. 2020 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):
T. J. Systems Properties, LLC tim tipanel. com
Name E-mail Address
269 Marble Road
Current Mailing Address
Statesville, NC 28625
City State Zip
Telephone [phone]
Current Street Address
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
E-mail Address
Current Street Address
City State Zip City
Telephone
Fax Number
State 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:
Timothy H. Johnson
Name of Registered Agent
269 Marble Road
Current Mailing Address
Statesville, NC 28625
City State Zip
[e-mail]
E-mail Address
Current Street Address
City
Telephone [phone] Fax Number.
State
Zip
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.
Timothy H. Johnson
Type or print name
Signature
I, Stephen M. Sha
Managing Member
Title or Authority
October 03, 2022
Date
a Notary Public of the County of I redel I
State of North Carolina, hereby certify that Timothy H. Johnson 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 3rd day of October , 20 22
<� h �kg,
Stephen M. Sharpe Notary
NOTARY PUBLIC
Iredell County, NC
My Commission Expires 01-25-25
My commission expires 01-25-2025
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