NCC221207_FRO Submitted_20220329

PLAN REVIEW/FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres as covered by the Ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Catawba County
Utilities and Engineering Department. (Please type or paint, and if question is not applicable, please N/A in the blank)
PART A
1. Job Name Maiden Turf Field
2. PIN or 911 Address 1364717119119
3. Purpose of development (residential, commercial, industrial, institutional,etc.) athletic
4. Approximate soil disturbance date 13/10/22
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.57
6. Has an erosion and sedimentation control been tiled? r' yes F No r Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes FX_ No
Account Number NA
PEOPLE
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name TBD DUSTIN BOURDREAU E-mail address [e-mail]
Telephone [phone] Cell # FSAME Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name REMBERT ENTERPRISES LLC Telephone Fax #
Current Mailing Address 140 E MAIN ST
City MAIDEN State NC Zip F28650
Current Street Address SAME
City State Zip
F_
10. Deed Book No. 3682 Page No. 1035
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 attached sheet):
Name IREMBERT ENTERPRISES LLC
E-mail address REMBERTGRANT@GMAIL..COM
Current Mailing Address 40 E MAIN ST
City MAIDEN State NC Zip F8650

Current Street Address
City State Zip
Telephone Fax #
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 NA E-mail address
Current Mailing Address
City State Zip
Current Street Address
City State Zip
Telephone Fax #
2. (b) If the financially responsible party is a Partnership or other person engaging in business under 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 I E-mail address
Current Mailing Address
City State
Current Street Address
City I State
Telephone Fax #
Zip
Zip
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 be any change in the information provided herein.
Type or Print Name Title of Authority
Signature Date
I, E e✓ C L'r+ d �� na Notary Public of the County of C0t4-O.rRD b R' State of North
Carolina, hereby certify that r eun.l— 12 C-i-A b e-►- 4- appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
Wit, ���anx[ i'1xj�tary seal, this �5 day of F , 20 Z ,
Notary ' I f
i z
PuBO�,'?US` My Commission expires I t I S
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