NCC216408_FRO Submitted_20211116

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,I 1: SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY I 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 andlor fax information unavailable, place NIA in the blank.)
Part A Q
1. Project Name
2. Location of land -disturbing activity: Latitude :;J5, 14Sal4") Longitude
Parcel Identification Number (PIN) e2' Watershed Area IaC3�_
Highway/Street Address T' :;?nD' 1nE_
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): �iLC�JI
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): L
6. Amount of fee enclosed: $ 1/c � . The Standard Permitting app[cation 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 '
3. Local appointed person to`contact should erosion and sediment control issues arise during land -disturbing activity:
Name �eilL �Ol_# E-mail Address ®eXilftiU U] �Ci! �C-ti� .cb�y\
TelephoneE-0 i7iZ`f�1 [/ Cell # Fax # pis
9. Landowner(s) of Record (attach accompanied page to list additional owners):
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Name Telephone Fax Number
t0 'ZtV COMNr0 s Pfau .*e---
Current Mailing Address Cu re�eet Address
City Mate Zip
City
State
Zip
10. Deed Book No. Page No. most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name Telephone Fa plumber
Z2.1.�n�
Current Mailing Address Current Street Address
_ "mowPjc, �7 Lsi Vlr_4,r+th QC, 2,00 z—
City State Zip City Statd Zip

M - SOIL EROSION and SEDIMENTATION CONTROL
a Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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):
�- ` D @, ma,; corn
Name E- ail Addres I Ili
Current Mailing Address t Current Street Address
l
City Mate Zip City State Zip
Telephone�� ���ZZ �]©,) 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
City State
Telephone.
Current Street Address
Zip City
Fax Number
State Zip
(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:
ctir Y•c� 'SO ` ' nA tcyC.c Corm
Name of Registered Agent E- ail Ad ess
�� Up� } � C
Current ailing Address Current Street Address
G so L_� Lr?' 2&qz__
City State Zip City State Zip
Telephone by gpZ7 dam} 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:
Engineering Firm or other consultant E-mail Kddress
Current Mailing Address , City \ r Statd Zip
Individual contact person (type or print) ~Telephone Fax Number

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
(d) Contractors and/or Subcontractors (person(s) or tirm(s) engaging in the land -disturbing activity:
Name of Person or Firm Name of Person or Firm
Current Mailing Address
Current Street Address
City State Zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone
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
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.
Type o� print name Title or Authbrity
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Date
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I, r�Z a Notary Public- of the County of
State of North Carolina, hereby certify that �Qn�� t/V , 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 day of 20 0-�
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RO Notary
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