NCC224173_FRO Submitted_20221221

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 I Catawba VFD
2. PIN or 911 Address 5715 Hudson Chapel Road, Catawba, NC
3. Purpose of development (residential, commercial, industrial, itistitutional,etc.)l Government (Fire Dept.)
4. Approximate soil disturbance date 1 9-1-22
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) I
6. Has an erosion and sedimentation control been filed? r- Yes No Attached
j
7. If you have an Erosion Control billing account, would you like this to be billed? F Yes F-
j No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Tracy Rietzell E-mail address [e-mail]
Telephone 1_7089-0232 Cell # [ 704-995-7645 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name I Catawba Volunteer Fire Dept., Inc. Telephone -2306 Fax #
Current Mailing Address I P.O. Box 98
CityCatawba State NC zip 278 0!
I I I
Current Street Address 1078 North Main Street
City I Catawba State NC zip 28609
10. Deed Book No. 1_3572 Page No. 1727
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 Catawba Volunteer Fire Dept., Inc. E-mail address [e-mail]
Current Mailing Address I P.O. Box 98
Catawba NC zip State28609
City F I

Current Street Address 108 North Main Street
i —
City Cba atawState NC — Zip 1 28609
Telephone [ [phone] _ Fax # ( N/A
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 FN/A7 E-mail address
Current Mailing Address
City State C _ ` Zip
Current Street Address
City I 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 Donald Robinson E-mail address [e-mail]
Current Mailing Address P.O. Box 98
1
City Catawba -- State NC' Zip 1 28609
Current Street Address 108 North Main Street
City Catawba State NC Zip 28609
Telephone C�?-�J 3�2 -� 2?o 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.
-'Do�6 ter,
e o rin Till of,A, th
lgnature Date
I, 7 , a ary Public of the County of ' -�(�� W' V State of North
Carolina, hereby certify that eFtn appeared I3erso ally before me t ' day and being duly
sworn ack�,pW)T4kgt the�bove form was executed by him.
Witnes y h and nz�l se this day of , 20
r p,�R o 1
Seal o
C+ AUe�� o
My Commission expir
11