NCC230550_FRO Submitted_20230302

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 Sidetracked
2. Location of land -disturbing activity: County Iredell City or Township Statesville
Highway/Street Near HWY 1-70 & 1-77 Latitude 35.765960 Longitude-80.842670
3. Approximate date land -disturbing activity will commence: 12/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32.0 AC
6. Amount of fee enclosed: $ 5,600 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Scarpinato E-mail Address [e-mail]
Telephone Cell # 407-873-6025 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Engineered Polymer Solutions c/o Valspar [phone]
Name Telephone Fax Number
101 W Prospect Ave
Current Mailing Address Current Street Address
Cleveland OH 44115
City State Zip City State Zip
10. Deed Book No. 1078 Page No. 1572 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):
PCL Construction Services, Inc. [e-mail]
Name E-mail Address
6700 Forum Dr. #100
Current Mailing Address
Orlando, FL 32821
City State
Telephone [phone]
Same as mailing.
Current Street Address
Zip 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:
NRAI Services Inc. N/A
Name
E-mail Address
160 Mine Lake Court, Suite 200
160 Mine Lake Court, Suite 200
Current Mailing Address
Current Street Address
Raleigh NC 27615
Raleigh NC 27615
City State Zip
City State Zip
N/A
Telephone [phone]
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:
Eric Nixon
[e-mail]
Name of Registered Agent
E-mail Address
6700 Forum Dr. #100
6700 Forum Dr. #100
Current Mailing Address
Current Street Address
Orlando, FL 32821
Orlando, FL 32821
City State Zip
City State Zip
Telephone
407-363-0059
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.
Eric .on
Type o print name
Signat e
Construction Manager
Title or Authority
Date
I, Ill- l t'� MVal a Notary Public of the County of 11�
State of 14&4t-6rtre{+fla, hereby certify that ��. `��(�� 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 A day of - iM � P�91 \4 20 2-3
cam Cl c
Notary
Seal
a�1%y "0 CARLA MARCHI
Notary Public • State of F;onoa
+ 40 Commission # HH 328507
My Comm, Expires Nov 2. 2025
3onded through Nationji Notary Assr
My commission expires It b 2-6)74,
Page 2 of 2

Additional Landowner
Landowner(s) of Record (attach accompanied page to list additional owners):
The Sherwin-Williams Company
Name
101 W Prospect Ave
Current Mailing Address
Cleveland OH 44115
City State Zip
Telephone
Current Street Address
City
State
Fax Number
10. Deed Book No. 2912 Page No. 1139 Provide a copy of the most current deed.
Zip