NCC222774_FRO Submitted_20220803

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 NIA in the blank)
PART A
1. Job Name Catawba Springs
2. PIN or 911 Address 45,5146,5155,5156 Mark DriveHickory, NC 28502
3. Purpose of development (residential, commercial, industrial, institutional,etc.) residential
4. Approximate soil disturbance date 1- 5 -2 2-22
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.47
1, 1-- - _ I- I I . I---------- A
6. Has an erosion and sedimentation control been filed? F>Z': Yes r-j'No 17,1 Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r7l Yes F No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Allen Johnston E-mail address [e-mail]
Telephone Cell
704-326-6736 I Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
, LLC T Helmsman Homes,
Name ------- Telephone Fax #
Current Mailing Address 116 Gasoline Alley
City Mooresville State NCZip 28117
Current Street Address
City State Zip
10. Deed Book No. 1734 Page No. 568
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 Helmsman Homes, LLC E-mail address [e-mail]
Current Mailing Address 116 Gasoline Alley, Suite 105
ciMooresville State NC 28117 Zip ty

Current Street Address
City State Zip
Telephone I 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 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 E-mail address
Current Mailing Address
City
Current Street Address
State Zip
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
provi orrected inform should ere a any change in the information rovided herein
Type & PrirWf4amf Title of AuthoritF
14>1
Signature Date
I, 6 r S �,i ds&� , a Notary Public of the County of &I c o/17 State of North
Carolina, hereby certify that j , l aj41 appeared personally before me this day and being duly
ve sworn acknowledge that the aboform was executed by him.
poi$ t 4,and notary seal, this Z day of � t,,,� , 20 �
ash'--,
, Notar
' My Commission expires LO�1
' A
L IC Print Form
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