NCC232456_FRO Submitted_20230816

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
I. Job Name k C 41. 9. ....
2. PIN or 911 Address I H3 Mo Il s B bowv 12,3 61,trri ik ' PC . gibil973
' 3. Purpose of development(residential,commercial, industrial, institutional,etc.)I fz, )
4. Approximate soil disturbance date I g l aDa3 •
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) I 1 ,
6. Has an erosion and sedimentation control been filed? r Yes r No VA ttached
7. If you have an Erosion Control billing account, would you like this to be billed? i`" Yes P7No
Account Number I
PEOPLE
S. Person to contact should erosion and sediment control issues arise during land-disturbing activityc
Name I �ar,.�$s 1.r3�t�� Email address I l'l ®Adel ° S`�+�r��ci�o► 5.400"
Telephone I Cell# I '70+ a0 I-:?9`1 Fax# I
9,Landowner(s)of Record(attach accompanied page to list additional owners)
Name' Pr2'Al 2 Corparr bb*Iy^At4f Telephone !1OLf ,o7.- 50.5.9 Fax.# f
Current Mailing Address ral000 to-'ne.L C,h pe1
City I State I Jj Zip I OW 3
Current Street Address I e atok.h\
City I State I Zip I
10.Deed Book No. 16979 . Page No. I I 0 3
PART B
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on attached sheet):
"Name E-mailevs4-woo3 Dons vo't'l ry address /V1 ' b?e e h ovct,howQ GOB %
Current Mailing Address Iak j-7 ' po4- 1(4
City I C,turi. State I /1.1 C. Zip I 08 ``O.$..............._.. ...

,
Current Street Address 1 <SG rye
City ....... . .. State I....... .. ....... Zip I ..._...._..........
Telephone 10 3 S 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 f E-mail address I
Current Mailing Address
City I State I . Zip I
Current Street Address
City I State Zip I.........
Telephone I Fax# I
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 I E-mail address I
Current Mailing Address I
City I State I Zip I
Current Street Address I
City I State I Zip I
Telephone I Fax# I
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.
MA2L. -i-r( ‘JP ci usrRticrcoAJ
Type or Print Na e Title of Authority
�V/- 7 2/. 202-3
Signature Date
I, • o I Y'- ,a Notary Public of the County of 1. ► tco 1 Vi State of North
Carolina,hereby ertify that 3 appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
�1 A JJ
Witness my han,4008i ynrgal,this a`F day of �Ul, 6 0Pi3
S�� d
',®TAf?J- Notar
1
i My Commissio a Tres 3•-'/ /--2
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