NCC216469_FRO Submitted_20211118

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, place N/A in the blank)
PART A
1. Job Name Apistolic Tabernacle of Newton, NC
2. PIN or 911 address 3639-0917-2177
3. Purpose of development (residential, commercial, industrial, institutional, etc.) Institutional
4. Approximate soil disturbance date ASAP
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4 Acres
6. Has an erosion and sedimentation control plan been filed? Yes No - Attached X
7. If you have an Erosion Control billing account, would you like this to be billed? Yes__ No x
Account number N/A
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Truecraft Builders, Inc. E-mail address [e-mail]
Telephone [phone] Cell # 980-429-0624 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Apistolic Tabernacle of Newton
Name
327 West 15th Street
Current Mailing Address
980-429-0624 (Caleb) N/A
Telephone Fax Number
327 West 15th Street
Current Street Address
Newton NC 28658 Newton
City
10. Deed Book No. 3666
State Zip City
Page No. 0096
NC 28658
State Zip
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):
Truecraft Builders, Inc.
Name
621 Clark Creek Road
Current Mailing Address
Lincolnton NC 28092
City State Zip
828-428-3580
Telephone
calebw cAtruecraftbuilder.com
E-mail Address (REQUIRED)
621 Clark Creek Road
Current Street Address
Lincolnton NC 28092
City State Zip
N/A
Fax Number
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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
2. (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:
Pauletta R. Williams
[e-mail]
Name of Registered Agent
E-mail Address
621 Clark Creek Road
621 Clark Creek Road
Current Mailing Address
Current Street Address
Lincolnton NC 28092
Lincolnton NC 28092
City State Zip
City State Zip
828-428-3580
N/A
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 authoritv to execute instruments for the Financiall v
Responsible Person). I agree to provide corrected information should there be any change in the information provided
herein.
Caleb P. Williams
pe or print name
Ab
Signature
President
Title or Authority
10
DS ar
Date
a Notary Public of the County of
Li c�cr�► r,
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledge that the above form was executed by him.
Witness my hand and notary seal, this �- day of
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