NCC240950_FRO Submitted_20240409

IREDELL
i COUtJTY NC
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 Control Act and the Iredell County Land Development Code, before this form and an acceptable erosion
and sedimentation control plan have been submitted and approved by the Iredell County Development Services, Planning Division-
Erosion Control Section. (Please type or print.)
Part A.
1. Project Name Doosan Parking Expansion
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Glenway Drive Latitude 35 48 ' 52"N Longitude 80"51 ' 45"W
3. Approximate date land-disturbing activity will commence: 0 9/2 019
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site,bon.. a d waste areas): 3 . 2 Acres
6411
6. Amount of fee enclosed: $ 7 0 0 . 0 0 �. An applicat f.n 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 .5 acre but < 1.0 acre
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 land-disturbing activity:
Name Seth Hathcock E-mail Address [e-mail]
Telephone Cell# 704-903-8848 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Clark Equipment Company
Name Telephone Fax Number
250 East Beaton Drive 250 East Beaton Drive
Current Mailing Address Current Street Address
West Fargo ND 58078 West Fargo ND 58078
City State Zip City State Zip
10. Deed Book No. 190 6 Page No. 217 8 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):
Clark Equipment Company
Name E-mail Address
250 East Beaton Drive 250 East Beaton Drive
Current Mailing Address Current Street Address
West Fargo N0 58078 West Fargo ND 58078
City State Zip City State Zip
Telephone Fax Number

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:
L A OW M AT kJ E 1 WL:, MArprR.N (q i oosAN. GOP')
Name E-mail Address
/273 LeN 141/1jy f
Current Mailing Address Current Street Address
.S- /,-ri vii.2 t; N C 28 ZS'
City State Zip City State Zip
Telephone 701 7?t/ /3 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 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.
L.ANCI /Vl ATHr RrJ S ihee PrzrfsitrAii . )prcjR/A� / O (JGT Y
Type or print name Title or Authority
,76,n /0 -20Signs e Date I
I, ' r y A-4-'tecerry ,a Notary Public of the County of -Tr &€
State of North Carolina, hereby certify that Lo.►-•C. f^'lo1+kern 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 is day of 5amuctry , 20 Z�{
Notes
Seal
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