NCC232840_FRO Submitted_20230929

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
41*
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbhg activity on one or more acres, 1/2 acre or more inside a
h; T v r C watershed, as covered by the Se-dimeitation 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 F'lanniig&Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Berl ' s Commercial Supply
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Thunder Rd Latitude 35 . 621150 Longitude -8 0 . 8 0 6 3 3 0
3. Approximate date land-disturbing activity will commence 0 a/01/2 0 2 3
4. Purpose of development(residential,commercial, indust-ial, irstitutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3 .8
6. Amount of fee enclosed: $ 7 0 0 . Ar appl cation 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 fiat fee of$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control iues arise during land-disturbing activity:
Name Butch Bouwens E ail address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list add tonal owners):
NORRIBLE LLC 704-937-2677
Name Telephcne Fax Number
129 Oak Park Dr 129 Oak Park Dr
Current Mailing Address Current Street Address
Mooresville NC 28115 Mooresville NC 28115
City State Zip Ci-y State Zip
10. Deed Book No. 2 971 Page No. 195 6 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):
NORRIBLE LLC Chris@berls .com
Name E-nail Address
129 Oak Park Dr -29 Oak Park Dr
Current Mailing Address Current Street Address
Mooresville NC 28115 Mooresville NC 28115
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:
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 Jerson engaging in business under an assumed name, attach
a copy of the Certificate of Assumed Name. If the Firancially 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 Ci-y State Zip
Telephone Fax Number
The above information is true and correct to the best of my knpwlecge 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.
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Sign Date
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I, t -Ir ca Nii 1E,•1 E-i2 ti ,a Notary Public of the County of C1 i-0-0.S
State of North Carolina, hereby certify that�a4tiS O"r)71ei %A0ZZt6 9L_/ _ appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal,this C• day of L t./c. ' / , 20. /; ) -
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