NCC240814_FRO Submitted_20240410

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. Job Name 1140 Hwy 321 Redevelopment
2. PIN or 911 Address '279208893899,279320803117,279320804252,279320805198,279320806199,279320802153,2793208033%
3. Purpose of development(residential, commercial, industrial, institutional,etc.)Commercial
4. Approximate soil disturbance date I4/1/2024
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 17.5
6. Has an erosion and sedimentation control been filed? r Yes r No 17 Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes 17 No
Account Number I
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name 'Jason Richardson E-mail address [e-mail]
Telephone ' Cell# 1828-320-8210 Fax# I
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name'See attached deeds Telephone ' Fax# I
Current Mailing Address I
City I State I Zip I
Current Street Address I
City I State I Zip I
10. Deed Book No. 'attached Page No. I
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 (Colson Park Capital,Inc. E-mail address [e-mail]
Current Mailing Address IPO Box 3967
City 'Hickory State INC Zip 128603

Current Street Address 106 2nd St NW-Third Floor
City 'Hickory State INC Zip 128601
Telephone Fax# I
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 I
Current Mailing Address
City ' State Zip I
Current Street Address
City ' State I Zip I
Telephone Fax# I
2. (b) If the fmancially 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
Current Mailing Address I
City I State I Zip I
Current Street Address I
City I State Zip
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.
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Ty se or Print Name Title of Authority
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Si: rre Date
I, e0,1 U 11 r`Q , a Notary Public of the County of b(h-4 Coarit4 State of North
Carolina,hereby certify that )as)),'N ig;CJ' Ac3w\ appeared personally bef e me this day and being duly
sworn acknowledge ttlat.the,abge form was executed by him.
Witness my hay notary sea ', trs 5 day of-�rjeVA12t,/ ,202,11
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tCts C/g'BUG My Commission expires U 2012,021
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