NCC223795_FRO Submitted_20221110

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.JobName I cl,'vW, UiiMe Nag 3
2. PIN or 9l l Address I `614 3 (o u 3 ► aclu
3. Purpose of development (residential, commercial, industrial, institutional,etc.)le84denfj' a 1
4. Approximate soil disturbance date a1 z/2P'?'
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) I 2" s of
6. Has an erosion and sedimentation control been filed? IX Yes F No F Attached
7. If you have an Erosion Control billing account, would you like this to be billed? f" Yes F No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name �eor�e- jar }lCClvveil E-mail address
6carralled Yhorlorl .carn
Telephone IN-1o20-1373 Cell # 1-0-0 ,e_ Fax # I Mjr,
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name I ck e V illw Telephone I Fax # Nil':
Current Mailing Address 50175 CQrvie5ic 31vd., S-L41 ie 2t�p
City State zip ["18767
Current Street Address COC12raCa r vte5te �}vd ,
City C�_&V1o}re State NG Zip '2626q
10. Deed Book No. 3! Page No. 0 b bi
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 I D.R. RoYfvrj, JhC..1 %ear9t ;QY,f q �iro)f E-mail address bCaYr®l t @ drhk'r4on. cam
Current Mailing AddressArrOwr,d 9t Blvd
City C�av 10� State Iey Zip ZSz�3

Current Street Address &Z5 M ytvjyid�e i6W&
City N(V[Ole State NC � zip
Telephone "lbu - { W_ -13-�3 Fax # Nl R
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 I E-mail address
Current Mailing Address
City State
Current Street Address
City State
F_ 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 Cr COV pOYO}).byl ��S�em \ E-mail address -wk'Fo e C,VciclVctiritaye cow,
Current Mailing AddressF lbD mire W'�e Ck [ smik, 2.6b
City uei�h State F�
N L Zip I Zl 6
Current Street Address K11OZ, tuve L}' � ff_ Zoo
City p State N L Zip T1615
Telephone ����_$��_�lt�� Fax# NIA
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.
660Y4WDES mapwlgey-
Ty or Prin ame Title of . uth rity
�t 'ZG 2 �--
Sign ure Date
L r u 'Q 4f�
Notary Public of the Co un y of State of North
Carolina, her y certify thata,rr appeared personally befor me this day and being duly
sworn acknowledge that the aboveexecutev him.
Witness my hand apd n6t rl, th:s; j day of 1/�1%12 , 20 Zl-
Seal E `
Notary
.. ". _ My Commission expires qzoZ7
Print Form
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