NCC240236_FRO Submitted_20240126

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
R 1. 1 ) [ I No person may initiate any land-disturbing activity on one or more acres, Y2 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 Project Artist-Dominion Gas Line Erosion Control
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Dover Road Latitude 35.7443 Longitude -80.8520
3. Approximate date land-disturbing activity will commence: November 15, 2023
4. Purpose of development(residential,commercial, industrial, institutional,etc.): linear utility
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 19.00
6. Amount of fee enclosed:$ 3,325 . 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 No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Murphy (Choate Construction) E-mail Address [e-mail]
Telephone [phone] Cell# 704.363.0174 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
GS Statesville Green Land, LLC 203-682-7466
Name do Greenfield Partners, LLC Telephone Fax Number
1 E. Putnam Ave, 3rd Floor same
Current Mailing Address Current Street Address
Greenwich, CT 06830
City State Zip City State Zip
10. Deed Book No. DB 1867 Page No. Pg 217 Provide a copy of the most current deed.
DB 1951 Pg 2262
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):
GF Statesville Parcel L Property Owner, LLC [e-mail]
Name E-mail Address
1 E. Putnam Ave, 3rd Floor same
Current Mailing Address Current Street Address
Greenwich, CT 06830
City State Zip City State Zip
Telephone [phone] Fax Number
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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:
CT Corporation System [e-mail]
Name E-mail Address
160 Mine Lake Ct, Ste 200 same
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number 919-844-8364
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Ra.esh Menon Authorized Agent
Type or pr.' me Title or Authority
Signat Date
I, \- ,0 I0, va''ve-Z ,a Notary Public of the County of %(ci>°Id
State of North€drotina, hereby certify that 12-1, e \ M-C,00C\ appeared personally before me this day
and being duly sworn acknowledged that the above fotm was executed by him.
Witness my hand and notarial seal,this Iday of C ,( ,20 2-3 •
Not
Seal
My commission expires
PAULA VASQUEZ
NOTARY PUBLIC
State of Connecticut
My Commission Expires
March 31,2027
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