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HomeMy WebLinkAboutNCC223587_FRO Submitted_20221104FINANCIAL 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 704-577-9021 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 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 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 Page 2 of 2