NCC242379_FRO Submitted_20240805

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
COUNTY NC 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 Side Tracked - Sherwin Williams
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Side Track Drive Latitude Longitude
3. Approximate date land-disturbing activity will commence: August 19th, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 35 Acres
6. Amount of fee enclosed: $__9,625.00 . An application fee of$275.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $2475). 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Mead E-mail Address ([e-mail]
Telephona Cell# [phone] Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Engineering Polymer Solutions C/O Valspar [phone]
Name telephone Fax Number
188 Side Track Drive 188 Side Track Drive
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. Page No. 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):
Gilbane Building Company [e-mail] (Evan Synstad)
Name E-mail Address
620 S. Tryon Street 620 S. Tryon Street _
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone[phone] _ Fax Number

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTAT
ION CONTROL
IREDELL
fi� r ti N c No person may initiate any land-disturbing activity on one or more acres, 1/22acre 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 lredell County Planning &Development, Erosion Control Section.
(Please type or print.)
Part A.
1. Project Name Project Side Tracked - Sherwin Williams
2. Location of land-disturbing activity: County lredell City or Township Statesville _
Highway/Street Side Track Drive Latitude Longitude
3. Approximate date land-disturbing activity will commence: August 19th, 2024
4. Purpose of development(residential,commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 35 Acres
6. Amount of fee enclosed:$ 9,625.00 . An application fee of$275.00 per acre(rou.ided up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $2475). 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Mead E-mail Address [e-mail]
Telep-innP Cell# [phone] Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Engineering Polymer Solutions C/O Valspar [phone]
Name Telephone Fax Number
188 Side Track Drive 188 Side Track Drive
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State —Zip
10. Deed Book No. Page No. -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):
Welty Building Construction, Ltd. [e-mail] (Paul Becks)
Name E-mail Address
3421 Ridgewood Road - Suite 200 3421 Ridgewood Road - Suite 200
Current Mailing Address Current Street Address
Fairlawn OH 44333 Fairlawn OH 44333
City State Zip City State Zip
Telephone[phone]
_ 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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
adWelty-Gilbe. aneis fed Agent: [e-mail] (Evan Synstad)
EID #99-3935678 [e-mail] (Paul Becks)
Name of Registered Agent E-mail Address
620 S. Tryon Street 7 Jackson Walkway
Current Mailing Address Current Street Address
Charlotte NC 28202 Providence RI 02903
City State Zip City State Zip
Telephone [phone] 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 infor ation should there by any change in the information provided herein.
Don Skinner Project Manager
Type Tint Title or Authority
f 8/2/2024
Soh re pate
I, Cos21 Z. tc nri. .-.11 _, a Notary Public of the County of Lint c r,
State of North Carolina, hereby certify that Don SK;nnGe 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 (71 day of ' J ri- ,20 _
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Seal .`11tll1JJ// Notary -/A ! -1
\\,\` �1 M C/ , '/ ,' My commission expires U5 ja?S i!.20.2L
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