NCC222145_FRO Submitted_20220613

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELL 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 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 Narne NC Park 40177
2. Location of land -disturbing activity: County Iredell City or Township Statesville
Highway/Street Crawford Rd Latitude 35.82025720941661—Longitude -80.8508008853894
3 Approximate date land -disturbing activity will commence: June 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 43.5
6. Amount of fee enclosed $_ 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 Michael Johnston E-mail Address [e-mail]
Telephone Cell # 614.546.9850 Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners)
See attached sheets
Name Telephone Fax Number
Current Mailing Address Current Street Address
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):
NP BGO NC Park Statesville, LLC
Name E-mail Address
4825 NW 41 st Street, Suite 500
Current Mailing Address Current Street Address
Riverside MO 64150
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:
Karen Rozar c/o CT Corporation System [e-mail]
Name E-mail Address
160 Mine Lake CT, Suite 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone
877.564.7529
Current Street Address
City State Zip
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake CT Suite 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
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.
Nathaniel Haaedorn
Type or print name
Sig re
Authorized Person
Title or Authority
-3k�o
Date
t. HIV a Notary Public of the County of
State of Missouri hereby ify that J j7 Oy'r1 appeared personally before me this day
and being duly sworn acknowledged that the above form was executecoy him.
Witness my hand and notarial seal, thisday of 20�
tary
.q,.
LISA L BEASLEY
Notary Public - Notary Seal
Platte County State of Missouri
Commission Number 19497557
My Commission Expires Sep 10, 2023
My commission expires -16 -dJ
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