NCC240706_FRO Submitted_20240415

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project Name Davidson Pointe Phase II
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street 236 Bridges Farm Road Latitude 35.5182 Longitude-80.8478
3. Approximate date land-disturbing activity will commence:3/18/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.55
6. Amount of fee enclosed: $ 300 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00).
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 Alex Deal E-mail Address [e-mail]
Telephone[phone] Cell # [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
JES LAND, LLC [phone]
Name Telephone Fax Number
126 Millport Circle, Suite 200 126 Millport Circle, Suite 200
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
10. Deed Book No.2466 Page No.2308 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
JES LAND, LLC [e-mail]
Name E-mail Address
126 Millport Circle, Suite 200 126 Millport Circle, Suite 200
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
Telephone[phone] Fax Number(864) 242-0245

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:
Michael Johnson [e-mail]
Name E-mail Address
323 Walnut Street 323 Walnut Street
Current Mailing Address Current Street Address
Statesville, NC 28677 Statesville, NC 28677
City State Zip City State Zip
Telephone[phone] Fax Number [phone]
(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:
W. Donald Shaw [e-mail]
Name of Registered Agent E-mail Address
126 Millport Circle, Suite 200 126 Millport Circle, Suite 200
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
Telephone[phone] Fax Number [phone]
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 be any change in the information provided herein.
W. Donald Shaw President
ype or print name Title or Authority
1)1 % (,( (c 3/11/2024
Signature Date
Lassie Jeffries , a Notary Public of the County of Greenville
State of North Carolina, hereby certify that 1A)- ( of ait Vj 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 1 day of March 20 24
otary
Seal
My commission expires \T2.i 2-0 2�i