NCC232942_FRO Submitted_20230928

�� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
4, EROSION & SEDIMENTATION CONTROL
IR E LJ E L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
( ;) N r v 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 Dollar General - Statesville
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Hwy 115 Latitude 35.695793 Longitude-80.522979
3. Approximate date land-disturbing activity will commence: April 2023
4. Purpose of development(residential,commercial, industrial,institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.31 acres
6. Amount of fee enclosed:$ 525.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Strickland E-mail Address [e-mail]
Telephone [phone] Cell# 704-224-7364 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
David Nicholson
Name Telephone Fax Number
270 Hams Grove Road 270 Hams Grove Road
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. 2768 Page No. 1676 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):
Teramore Development, LLC jstricklandateramore.net
Name E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury NC 28144 Salisbury NC 28144
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

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, part - ,or registered agent with the authority to execute instruments for the Financially Responsible Person). I agree to
provide cor e ed information should there by any change-irrtheinformation provided herein.
Joe S •• land Agent
Type or r ' Title or Authority-....00r /- i-7 ��/�
sign• '� Date
1, �"�N f `� +�9 ,a Notary Public of the County of Po AN
State of North Carolina, hereby certify that N-0 r S'1/2-F C(t LA Nt,)-'/ 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 17 �rday of NV M . ,20 3
DANIE ALMAZAN Notary
NO PUBLIC My commission expires vNl` �S✓ 2-c 2. 7
'rowan County, North Carolina
Ay Commission Expires June 28,2027
Page 2 of 2

9. Landowner(s)of Record(attach accompanied page to list additional owners):
Tommy& Sarah Taylor
Name Telephone Fax Number
172 Mason Lane 172 Mason Lane
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. 2643 Page No. 87 Provide a copy of the most current deed.

9. Landowner(s)of Record (attach accompanied page to list additional owners):
Mark Cowles
Name Telephone Fax Number
126 Jacob Drive 126 Jacobs Drive _
Current Mailing Address Current Street Address
Statesville NC 28625 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. 2478 Page No. 835 Provide a copy of the most current deed.