NCC221735_FRO Submitted_20220505

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP 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 print, and if question is not applicable, please N/A in the blank)
PART A
1. lob Name (Christ Alive Church New Recreation Building
2. PIN or 911 Address 11549 Southwest Blvd., Newton, NC
3. Purpose of development (residential, commercial, industrial, institutional,etc.) Institutional
4. Approximate soil disturbance date May, 2022
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.75 Acres
6. Has an erosion and sedimentation control been filed? F Yes r No FX- Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes r No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Sam King, Jr. E-mail address [e-mail]
Telephone [phone] r Cell # 828-403-5586 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name Christ Alive Church Telephone [phone] Fax #
Current Mailing Address I1549 Southwest Blvd.
City Newton State North Carolina ZipF8658
Current Street Address 11549 Southwest Blvd.
City Newton State North Carolina ZipF8658
10. Deed Book No. 2877 Page No. 578
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 Christ Alive Church E-mail address Ichristalivechurch.com
Current Mailing Address 1549 Southwest Blvd.
City Newton State North Carolina Zip r28658

Current Street Address 11549 Southwest Blvd.
City Newton State North Carolina Zip 28658
Telephone [phone] 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 E-mail address
Current Mailing Address
City State
Current Street Address
City I State
Telephone
I Zip I
IZip
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 Mark A. Ivey E-mail address [e-mail]
Current Mailing Address 11549 Southwest Blvd.
City Newton State North Carolina ZipF8658
Current Street Address 1549 southwest Blvd.
City Newton State North Carolina Zip F8658
Telephone [phone] Fax #
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.
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Signature Date
I, 0 )1 1<f yY, , a Notary Public of the County of CA'TPA JZf4 State of North
Carolina, hereby certify that AR appeared personally before me this day and being duly
sworn acknowledge that the above form was executed b h .
h S Tp day ZZ Witness my hand and notary s@3►\ �i y of 20
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