NCC240660_FRO Submitted_20240320

FgN' SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
4... 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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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 Division. (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 fro D \ Corn me✓U c� '►�U i 1cL,
1. Project Name_
2. Location of land-disturbing activity: Latitude 35.538 Longitude -81.042
Parcel Identification Number(PIN) 3695266814 Watershed Area WS-IVP
Highway/Street Address N NC 16 BUSINESS HWY
3. Approximate date land-disturbing activity will commence: completed
4. Purpose of development(residential,commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.23 acre s
6. Amount of fee enclosed:$_ cw .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 X No Enclosed
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name BILL ZEMAK E-mail Address BILL a BELLATONY.CON
Telephone [phone] Cell# [phone] Fax# NA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
GRAHAM PARK LLC [phone] [phone]
Name Telephone Fax Number
8520 NORMAN ESTATES DR 8520 NORMAN ESTATES DR
Current Mailing Address Current Street Address
DENVER NC 28037 DENVER NC 28037
City State Zip City State Zip
10. Deed Book No. 2838 Page No. 991 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
N/A N/A N/A
Name Telephone Fax Number
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip

° N
O-, SOIL EROSION and SEDIMENTATION CONTROL
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Lincoln County Natural Resources Division
NATURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RESOURCES!
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):
GRAHAM PARK LLC [e-mail]
Name E-mail Address
8520 NORMAN ESTATES DR 8520 NORMAN ESTATES DR
Current Mailing Address Current Street Address
DENVER NC 28037 DENVER NC 28037
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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 ame and street address of the Registered Agent: \ 1
N/A 1�1 ZMak N/A \\� 110.T c p y
Name of Registered Agent E-mail Address
N/A 85-a,b Nod`MA(\ zisQs N/A Sam
Current Mailing Addresss�` Q'J� '7 Current Street Address
NO,eA'I c NAit C' �43 n ( N/A coot 'N/A N/A
City Statea Zip City State Zip
Telephone N/A 7d 30 1406C( Fax Number N/A
(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:
SWARTZ DESIGN AND ENGINEERING, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
585 B AND T LN TAYLORSVILLE NC 28681
Current Mailing Address City State Zip
JEFF SWARTZ, PE [phone] [phone]
Individual contact person (type or print) Telephone Fax Number

.c (' .. SOIL EROSION and SEDIMENTATION CONTROL
:y� = Lincoln County Natural Resources Division
R" - 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:
BROWN CONSTRUCTION, LLC N/A
Name of Person or Firm Name of Person or Firm
3970 INDEPENDANCE BLVD, APT# 118 N/A
Current Mailing Address Current Street Address
WILMINGTON NC 28412 N/A N/A N/A
City State Zip City State Zip
-- N/A
Individual contact person (type or print) Individual contact person (type or print)
Telephone [phone] Telephone N/A
Fax Number -- Fax Number N/A
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 age is to enter on the land in question in connection and/or related to this permit.
Owntr
Type or i' tt Title or Authority
------ iMax\
Signature Date
I, —Pa ntet I T ?Vd,- lit ,a Notary Public of the County of L I n 0 b✓1
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State of North Carolina, hereby certify that (N)I it tiJ'`l.. 9e,lla,/4 appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 7 day of , 2 2
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