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Home My WebLink AboutNCC231854_FRO Submitted_20230706 8/24/22,11:30 AM Rowan County Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance No person may initiate any land-disturbing activity on one or more acres as covered by the ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County Environmental Management Department. Part A Parcel ID Number 063-066 ---1 1.Project Name Jake Alexander Self Storage 2.Location of land-disturbing activity(Highway/Street) r1700 Jake Alexander Blvd,Salisbury, NC 28144 Latitude Longitude 35.6425 80.4698 3.Approximate date land-disturbing activity will be commenced _i [11/1/2022_JI 4.Purpose of development(residential,commercial,industrial,etc.) Commercial 5.Approximate acreage of land to be disturbed or uncovered L2.842 AC 6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number activity 360-268-3813 Jerad Birindelli Email Address jastorage34@gmail.com https://www.rowancountync.gov/ForrnCenter/Print?formID=968Preview=YES&Save=False&savedProgressID= 1/3 8/24/22,11:30 AM Rowan County 7.Landowner of Record Landowner of Record Jake Alexander Storage,LLC Name Name Current Mailing Address Current Mailing Address 5979 Hill N Dale Dr. Kemersville,NC 27284 8.Recorded in Deed Book Number Page Number 1400 624 Part B 1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-disturbing activity land-disturbing activity Jake Alexander Storage,LLC Name of Person(s)or Firms) Name of Person(s)or Firm(s) Current Mailing Address Current Mailing Address 5979 Hill N Dale Dr.Kemersville,NC 27284 Phone Number Phone Number 360-268-3813 a.If the Financially Responsible Party is not a resident of North Carolina,give name and street address of a North Carolina Agent. Name of Agent Name of Agent Current Mailing Address Current Mailing Address Phone Number Phone Number https://www.rowancountync.gov/FormCenter/Print?formlD=968Preview=YES&Save=False&savedProgresslD= 2/3 8/24/22,11:30 AM Rowan County 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 the name and street address of the Registered Agent. Name of Registered Agent Reed Andrew Miller Current Mailing Address Current Street Address 5979 Hill N Dale Dr. Kemersville,NC 27284 Telephone Number Telephone 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 authority to execute instruments for the Financially Responsible Person). I agree to provide correctional information should there be any change in the information provided herein. Name Title or Authority Reed Andrew Miller 1 ati nG ✓ Signature Date flit mm/dd/yyyy! g/`Z‘72-°L 2— I, Srikkarti3 POrtY"," ,a Notary Public of the County of M'c4tw nc4 State off North Carolina, hereby certify that RQtd Anaktd PAIR appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her.Witness my hand and seal of Notary,this 24 day of AkATUS+- ,202 2. Notary My commission expires 6/'%-------------,- j mm/dd/yyyy OC;4-09 y z S i 2 02S Seal BRITTANY PARRISH NOTARY PUBLIC Checklist ALAMANCE COUNTY Download a copy of the Erosion and Sedimentation STATE OF NORM CAROdiNA Control Plan Checklist(PDF) https://www.rowancountync.gov/FormCenter/Print?formiD=968,Preview=YESBSave=False&savedProgressID= 3/3