NCC223587_FRO Submitted_20221104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one c e inside a
watershed, as covered by the Sedimentation Pollution a t 1 C unty Land
Development Code, before an acceptable erosion and sedi et la submitted
and approved by the Iredell County Planning & Development, Erosion Control Section.
(Please type or pnnt.) SEP 2 8 2022
Part A.
1. Project Name Proposed Distribution Center at Odessa Drive
2. Location of land -disturbing activity: County Iredell Cityor Township Statesville
Highway/Street Odessa Drive Latitude 35.82 Longitude -80.86
3. Approximate date land -disturbing activity will commence. _ July 19, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc ): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): R4.5 Acres Pvinusly permitted 80.5)
6. Amount of fee enclosed $ 700 . 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 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 $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_ x
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ Kathy Godley
Telephone [phone] Cell #
E-mail Address Kathy ftodleyorooerty com
9. Landowner(s) of Record (attach accompanied page to list additional owners).
4077 Industrial park, LLC
Name
20940 Bethelwood Lane
Cornelius NC 28301
City State Zip
Fax #
Telephone Fax Number
Current Street Address
City State Zip
10. Deed Book No. 2917 Page No. 2233 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):
4077 Industrial Park, LLC
Name
20940 Bethelwood Lane
Current Mailing Address
Cornelius NC 28301
City State Zip
Telephone
E-mail Address
Current Street Address
Cornelius NC 28031
City
Fax Number
State
Zip
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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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
State Zip City
Telephone 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 attomey-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 print name
Signature
/�4 irn rr
Title or Authority
1-23- 7-0z2.
Date
I, ,�SVi I ty L• aer L a Notary Public of the County of ,l Vl ('01 Ill
State of North Carolina, hereby certify that 6. &c� Gvj 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 `32&rn be'r- 20— L2�91VU'4 �e au'o�&
2Z
Notary
eal ASyLEY L. SHERRILL D� _oy_�T-�f
NOTARY PUBLIC My commission expires
Lincoln County, North Carolina
My Commission Expires 09104/2024
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