NCC232511_FRO Submitted_20230822

Print Form
4/P► SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R"rsouR s 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A
1. Project Name United Plate Glass Expansion
2. Location of land-disturbing activity: Latitude 35.548400 Longitude-81.234840
Parcel Identification Number(PIN) 3636521180 Watershed Area Larkhard Creek
Highway/Street Address 1104 Lincoln County Parkway
3. Approximate date land-disturbing activity will commence: 7/15/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial(expansion to ex bldg)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.40 acres
6. Amount of fee enclosed: $$1,350(3 acres x$450) . The Standard Permitting application fee of$200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 9 acres total $1,800).The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount. In addition,the Express Permitting supplement is$250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example: 9 acres total $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brandon Reisser E-mail Address [e-mail]
Telephone [phone] Cell# 910.583.4398 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Cully Investments, LLC(Attn: Michael Cully) 828.979.6100
Name Telephone Fax Number
108 Grundman Drive 108 Grundman Drive
Current Mailing Address Current Street Address
Butler PA 16001 Butler PA 16001
City State Zip City State Zip
10. Deed Book No.1893 Page No.845 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
N/A
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

411I4 t SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R"rsouR u 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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 an attached sheet):
Cully Investments, LLC (Attn: M. Cully) [e-mail]
Name E-mail Address
108 Grundman Dr 108 Grundman Dr
Current Mailing Address Current Street Address
Butler PA 16001 Butler PA 16001
City State Zip City State Zip
Telephone[phone] Fax Number
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:
Universal Registered Agents
Name E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone[phone] Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an 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:
Universal Registered Agents
Name of Registered Agent E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone[phone] Fax Number
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
OAK Engineering, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
4929 Monroe Road Charlotte NC 28205
Current Mailing Address City State Zip
Luke Bugenske 803.312.5074
Individual contact person(type or print) Telephone Fax Number

,a `�- (G SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Rgalt 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d) Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity
Frampton Construction
Name of Person or Firm Name of Person or Firm
4500 Cameron Valley Pkwy, Suite 220
Current Mailing Address Current Street Address
Charlotte NC 28211
City State Zip City State Zip
Brandon Reisser
Individual contact person(type or print) Individual contact person (type or print)
Telephone[phone] Telephone
Fax Number _ Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
Michael W. Cully Member
Type or print name Title or Authority
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Signature Date
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