NCC233609_FRO Submitted_20231207

Print Form
G, SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
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 Lot 3-Prestige Business Park
2. Location of land-disturbing activity: Latitude 35°25'56.67"N Longitude 81°25'44.31"W
Parcel Identification Number(PIN)102322 Watershed Area N/A
Highway/Street Address 7224 Jameson Way,Stanley, NC 28164
3. Approximate date land-disturbing activity will commence:October 1,2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.):commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):7.72
6. Amount of fee enclosed: $ 1,600 .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 Tommy Leppert E-mail Address [e-mail]
Telephone [phone] Cell# 704-751-71110 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Prestige Business Park, LLC 704-607-5059
Name Telephone Fax Number
7224 Jameson Way 7224 Jameson Way
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
City State Zip City State Zip
10. Deed Book No.3246 Page No.796 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

,�►° SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
uNATURAL
sou �s 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):
Prestige Business Park, LLC [e-mail]
Name E-mail Address
7224 Jameson Way 7224 Jameson Way
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Brandt Law PLLC
Name of Registered Agent E-mail Address
16140 Northcross Dr., Ste. B 16140 Northcross Dr., Ste. B
Current Mailing Address Current Street Address
Huntersville NC 28078 Huntersville NC 28078
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:
Bluestone Land Management, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
115 Autumn Frost Avenue Statesville NC 28677
Current Mailing Address City State Zip
Jonathan Carter 704-649-2863
Individual contact person(type or print) Telephone Fax Number

.A101., SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
i.
RM,Ias 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:
Prestige Site Works Prestige Site Works
Name of Person or Firm Name of Person or Firm
7224 Jameson Way 7224 Jameson Way
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
City State Zip City State Zip
Mike Knott Mike Knott
Individual contact person(type or print)Individual contact person(type or print)
Telephone
803-448-9620 TeleP hone803-448-9620
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 La •
I certify that I am aut•• zed . grant and do in fact grant permission to the Nat - -es%urces Erosion Control Inspector
and his agents t• -nter on e land in question in connection and/or related •this pe it.
Brian Mah. ey Managin• ember / /
Type o pri name /
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I, I 1 U✓1�9,K \-- 1(i.Y�L( , a Notary Public of the County of 1_IYI tv I VI
State of North Carolina, hereby certify that 1✓1 I0 11 YV appeared personally before
me this day and being duly sworn acknowled ed that the above form was executed by him.
Witness my hand and notarial seal,this 1 day of 20 a--3
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