NCC224145_FRO Submitted_20221219

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
Development Code, before an acceptable erosion and sed Whffo
I I�nty land
and approved by the Iredeli County Planning $ Developmer , E echon. suttmltted
(Please type or print)
Part A. NOV 2 1 2Fk
1. Project Name Onsrud - Lot 3&4
2. locatlan of land-disturbin a
6 cdvity: County Iredell City or Township Tnwtman
Highway/Street Technology Drive,,
Latitude 35.717 Longitude -80.889
3. Approximate date land -disturbing activity will commence: ❑@C@mbBr 1 2022 rtT
4- Purpose of development (residential, commercial, Industrial, institutional, etc.): INu
S. Total acreage disturbed or os<t=_retd ' luding off -site borrow and waste areas): 9.84
6. Amount of fee a ed: $ 11750�Ma-
An application fee of S175.00
per ecreassessed without ill am -scre application fee is $1575). For projects(rounded
thant 0.5 acres but acre)o the next isgreater 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_��
8. Person to contact should erosion and sediment control issues arise during sand -disturbing activity:
Name Talmadge C. Strickland IV [e-mail]
E-mail Address 9 @tcstl'ickland.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Onsrud Development, LLC
Name Telephone
Fax Number
120 Technology Drive 120 Tech
Current Mailing Address9y Drive
Curren# Street Address
C routman NC 28166 Troutman NC 28166
State Zip city State
Z1
10, Deed goon No. 15W Page No. 2166
Provide a copy of the most current deed. p
Part S.
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);
CR ONSRUD INC
Name
120 TECHNOLOGY DRIVE
Current Mailing Address
TROUTMAN NC 28i66
Clty stare Zp
Telephone [phone]
Tom Onsrud --tonsrudOR)cronsrud.com>
E-mail Address
120 TECHNOLOGY DRIVE
Current street Address
TROUTMAN NC 28166
Dity State Zip
Fax Number
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(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-maif Address
Current Melling Address
Currant Street Address
City State zP City State
Telephone 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 Warne and street
address of the Registered Agent
Z4 !Jn/5 2c�O Name of Registered Agent C ec/S2 L/i�
E-mail Address
D �oL07
Current Mailin Address o rG Na/r .
Current Street Address '
City �►-t.r C �� /�6
State Zip City
State Zip
Telephone Dy 5 D Da Fax Number 70 y 5 a 6
The above information is true and correct to the best of my knowledge and belief Individual, by an officer
Ind and was provided by me under oath
must be signed by the Financially Responsible Person if an individual or his attorney -in -fact or if not an ind,
director, Partner, or registered agent with the authority to execute instruments for the Financially Responsible Person . (This form
Provide corrected information should there by any change In the information Provided herein. P ) agree to
/ v cs,�.,r7L
T e or print name t:/,vSlzuD��
Title or Authority
Signature o D �Z
uais
a Notary Public of the County of [� a
--ram $
State of North Carolina, hereby certify that
and being duly swam acknowl S ✓ appeared personally before me this day
edged that the above fbrm was executed by him-
Wrtness my hand and notarial seal, this day ofXIVo r,N+
2UL —
Seal Notary
My commission expires — )7 -Z a
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