NCC232915_FRO Submitted_20230927

`„ °' SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NICIRAI _ 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
KCVIUHc.:-S
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A
1. Project Name Scooter's—Denver. NC
2. Location of land-disturbing activity: Latitude 35.461547 I nngitude -80 993011
Parcel Identification Number(PIN) 32058 Watershed Area WS-IVC
Highway/Street Address 7748 Deerborne Lane, Denver, NC 28037
3. Approximate date land-disturbing activity will commence: 8/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.89
6. Amount of fee enclosed: $ 200 00 The Standard Permitting application fee of$200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 9 acres total$1,800). The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre (rounded up to the next acre)is
assessed without a ceiling amount. In addition, the Express Permitting supplement is$250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total$3,800.00)
7 Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8 Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeff Watson E-mail Address watsonftousterdvo.com
Telephone Cell# 704.906 4491 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners)
Perry Claim Servireq I I C 704-791-314n
Name Telephone Fax Number
_2522 Green Point Lane
Current Mailing Address Current Street Address
Denver [K 28037..
City State Zip City State Zip
10. Deed Book No 7804 Page No. 331-334 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners)
7748 Deerborn Ave, LLC 704 Q06 4491
Name Telephone Fax Number
1470 F 7Lh Street, Suite 100
Current Mailing Address Current Street Address
Charlotte NC 28204-2408
City State Zip City State Zip

�► SOIL EROSION and SEDIMENTATION CONTROL
•-1 C.
Lincoln County Natural Resources Department
RMr sy- 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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):
7748 DeerbnrnJ anP, LI C watsongLoystezdvp corn
Name E-mail Address
_1420 E. 7th Street. Suite_1Q0 same
Current Mailing Address Current Street Address
Charlotte NC 28204-2408
�Ilr here e„tPr Ip't
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 address of the Registered Agent:
.lamps R Mcl end jim mrlenri@i alexanriarrirks rnm
Name of Registered Agent E-mail Address
1420 E 7th St, Suite 100
Current Mailing Address Current Street Address
Charlotte, NC 28204
City State Zip City State Zip
Telephone [phone] Fax Number
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Gaskins LeCraw/Kyle Sharpe [e-mail]
Engineering Firm or other consultant E-mail Address
Duluth GA 30090
Current Mailing Address City State Zip
Amy Wilby 678-257-1902

Individual contact person(type or print) Telephone Fax Number
�1►% SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R eiR cs 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
-CR r) - -
-
Name of Person or Firm Name of Person or Firm
Current Mailing Address Current Street Address
City State Zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone Telephone
Fax Number 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 and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to
enter
on the land in question in connection and/or related to this permit.
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TOe or print name' Title or authority ,J
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Ognoturc Date
I, (A 1,(;i1“.a. ('/v ! a Notary Public of the County of '_ttcV€44- ,o"5
State of North Carolina, hereby certify that �'"� R Me Le.•) 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,th•is a day of -)''4`4- ,20 �3
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Perry Claim Services, LLC
2522 Green Point Lane— Denver, NC 28307
June 19, 2023
Re: Scooter's — Denver, NC
7748 Deerborn Lane
689 NC 16 Business Hwy
Denver, NC 28037
Parcel ID # 32058
PIN 4602684892
I, 0. ( (r( herby
certify that I am the current property owner of the
property located at 7748 Deerborn Lane & 0.2licakialiatalln, Detive;, NC 28037 also known
as parcel ID no. 32058 per Ltncol,R County GIS. I as the current property owner per deed book /l ,
page 331, I hereby authorize, 7748 Deerborn Lane, LLC, the developer of said property, to be
financially responsible for any and all work associated with the proposed development of said parcel to
construct a Scooter's Coffee Shop.
The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath I agree to provide corrected information should there be any change in the information
provided herein.
Date: ‘/27/1.-7 Name Title a C/ M.r
Signature TT )
1, i e V ' r a No Public of the County of CiL
Lib14-h , ‘ ri
State of 4C1/<J
, hereby certify that I Pei' r appeared
D t
(41a-
personally, before me this day and being duly sworn acknowledged that the above form was executed by
him. Witness my hand and notary seal this ROlayof J K ,20uAt 3 .
i1� s
No �ycommission ex ires Ff� 1 0�.
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locg,
BRIDGETTE LIVENGQ0D
NOTARY PUBLIC
ROWAN COUNTY, NC
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LCommission ExpirescO