NCC216642_FRO Submitted_20211130

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 NIA in the blank)
PART A
1. Job Name Laurelbrook
2. PIN or 911 Address I PIN: 4609-0137-8911
3. Purpose of development (residential, commercial, industrial, institutional,etc.) RESIDENTIAL
4. Approximate soil disturbance date 10/01 /2021
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 250 AC
6. Has an erosion and sedimentation control been filed? F Yes F No (X Attached
7. If you have an Erosion Control billing account, would you like this to be billed? F Yes r No
Account Number
PEOPLE
8. 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 # [704-751-7110 Fax # I� �v
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name See Attached List Telephone �+ Fax #
Current Mailing Address
City State Zip
Current Street Address
City State
10. Deed Book No.Page No.
PART B
I� zip F
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 BBC Laurelbrook LLC E-mail address [e-mail]
Current Mailing Address 1 21000 TORRENCE CHAPEL ROAD STE. 100
City CORNELIUS State NC Zip 28031

Current Street Address
City State Zip
Telephone [phone] Fax #
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
CityF_ State Zip
Current Street Address
City State "Lip
Telephone Fax #
2. (b) If the financially 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 Brian Mahoney E-mail address [e-mail]
Current Mailing Address 21000 Torrence Chapel Rd, Ste 100
City Cornelius State NC Zip 28031
Current Street Address
City I State I Zip
Telephone [phone] Fax #
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.
Brian Mahoney , Manager
Title of Authority
.5-` 2 $'_ Zo Z )
Date
I, f , a Notary Publ
Carolina, hereby certify that 4
sworn acknowledge that the above form was executed by
is of the County of /4C4 /{„ hWg State of North
appeared personall before me this day and being duly
Witness my hand and notary seal, this ZS day of a , 20 ?/
Seal Chandler Turpin dl ,�I..—
NOTARY PUBLIC Notary
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