NCC243025_FRO Submitted_20241016

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, % acre or more inside a
t i T Y N C 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 HOUSTON ROAD INDUSTRIAL PROJECT e TROUTMAN
2. Location of land-disturbing activity: County IREDELL City or Township TROUTMAN
Highway/Street 240 Houston RD _Latitude_ 35.679° Longitude 480.850a
3. Approximate date land-disturbing activity will commence: September 25,2023
4. Purpose of development(residential,commercial,industrial,institutional,etc.) lndustalal
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 68.2 Acres
6. Amount of fee enclosed:$ $12,075.00 . 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 NoNo Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Mosser E-mail Address [e-mail]
Telephone [phone] Cell# 704-962-7557 Fax# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
CI 77 Troutman, LLC 704-206-8300 704-335-8654
Name Telephone Fax Number
1111 Metropolitan Ave.,Suite#700 1111 Metropolitan Ave.,Suite#700
Current Mailing Address Current Street Address
Charlotte, NC 28204 Charlotte, NC 28204
City State Zip City State Zip
10 Deed Book No. 2965 Page No. 870-872 Provide a copy of the most current deed.
2965 920-925
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):
CI 77 Troutman, LLC RMossert collettre.com
Name E-mail Address
1111 Metropolitan Ave.,Suite#700 1111 Metropolitan Ave., Suite#700
Current Mailing Address Current Street Address
Charlotte, NC 28204 _ Charlotte, NC 28204
City State Zip City State Zip
Telephone [phone] Fax Number744'335-8654
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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:
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
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
Michael Robbe Manager
Type r prin n e Title or Authority
49(1-4/23
Signature Date
I, /9(d0 -(abu/ ,a Notary Public of the County of ete4O0
State of North Carolina, hereby certify that Michael Robbe 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 O1co day of J(J rTQ, , 20 al
Nota•
(Ac,C(et--41-(t&C
Seal
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