NCC222104_FRO Submitted_20220607

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. Job Name IThe Hamptons at Hickory
2. PIN or 911 Address I371305177628
3. Purpose of development (residential, commercial, industrial, institutional,etc.) Residential
I
4. Approximate soil disturbance date 15/1/2022
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
6. Has an erosion and sedimentation control been filed? Fx_1 Yes r; No F Attached
7. If you have an Erosion Control billing account, would you like this to be billed? F Yes rl No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
i
Name Mark Hingson (HVY 1700, LLC) E-mail address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name HVY 1700, LLc Telephone [phone] Fax #
Current Mailing Address 1410 4th Street Dr NW #102
City Hickory State NC W Zip 28601
Current Street Address 1700 5TH ST NE
City Hickory j State NC _ Zip 28601
10. Deed Book No. 3741 �II Page No. 1482
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 IMark Hingson (HVY 1700, LLC) E-mail address [e-mail]
Current Mailing Address 11410 4th Street Dr NW #102
City Hickory _ State INC 'Zip 28601

Current Street Address 1410 4th Street Dr NW #102
City Hickory State NC Zip [28601
Telephone I(239) 707-5689 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 I State Zip F
Current Street Address
City State Zip
Telephone I 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
E-mail address
Current Mailing Address
City I State Zip
Current Street Address
City State Zip
Telephone I 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.
Mark Hingson
Type'op t Name
Si nature
I, C`6. L--W (
Carolina, h reby certify that
sworn acknowledge that the
Partner
Title f 4uthority
y? 1-2o QI
Date
a N tary Public of the County of (o ' h State of
Gt. 'a appeared personally before me this day and being duly
rbove form was execlA ed by him.
Witness my hand and notary seal, this C
Seal
G. KEVIN MtGRAW
PILIC
STATE OFRY
�SOUTH CAROLINA
MY CanmNsbn ExPlns
Now�bK i8, 202E
day of �2 , 20
Notary
My Commission expires ® ��
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