NCC215287_FRO Submitted_20210927

° =c SOIL EROSION and SEDIMENTATION CONTAR�etvv_o
j Lincoln County Natural Resources Department
NAT[1RAL�7 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RC50[1RC�51
FINANCIAL RESPONSIBILITY/ OWNERSHIP FOR..'"""ReSNuGe$
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 NIA in the blank.)
Part A
l . Project Name Church At Denver
2. Location of land -disturbing activity: Latitude35-470523 Long itude-80.995158
Parcel Identification Number (PIN)4603620186 Watershed AreaWS-IV
Highway/Street AddressAdjacent to 1452 Triangle Circle Denver, NC 28037
3. Approximate date land -disturbing activity will commence:611121 101611
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2 5
6. Amount of fee enclosed: $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 EnclosedX
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameDavid Johnston E-mail [e-mail]
Telephone[phone] Cell # 561.818.8107 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CHURCH AT DENVER NC 408.893.3784 NIA
Name Telephone Fax Number
274 N NC 16 HWY SUITE 100 274 N NC 16 HWY SUITE 100
Current Mailing Address Current Street Address
Denver NC 28037 Denver NC 28037
City Slate Zip City State Zip
10. Deed Book No.2853 Page No.975 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
NIA
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
NATURAL ---r 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax. 704
RE5-736-8504
0URCC5!.
FINANCIAL RESPONSIBILITY 1 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):
CHURCH AT DENVER NC [e-mail]
Name
274 N NC 16 HWY SUITE 100
Current Mailing Address
Denver NC
City State
Telephone[phone]
E-mail Address
274 N NC 16 HWY SUITE 100
Current Street Address
28037 Denver NC 28037
Zip City State Zip
Fax Number N/A
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
Current Mailing Address
E-mail 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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
Zip
(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:
CES Group Engineers LLP [e-mail]
Engineering Firm or other consultant E-mail Address
274 N. Hwy 16 Business, Ste 300 Denver NC 28037
Current Mailing Address City State Zip
Sean Coldren 704.489.1500 NIA
Individual contact person (type or print) Telephone Fax Number

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_� SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NATUK"AL _71 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
, rcesouRcesr
FINANCIAL RESPONSIBILITY/ OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
TBD
Name of Person or Firm
Current Mailing Address
Name of Person or Firm
Current Street Address
City State Zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
Tele
Fax Number
Telephone
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.
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Signature
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Ti le or Authority
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Date
f d M fe Qp /Ja Notary Public of the
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State of North Carolina, hereby certify that 15fitci/ W. SICK appeared personally before
me this day and being duly sworn acknowledged that fhe above form was executed by him.
Witness my hand and notarial seal, this day of A PRIL 20o?
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