NCC216811_FRO Submitted_20211214

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 N/A in the blank)
PART A
1. Job Name I LOVELAND TOWN HOMES
2. PIN or 911 Address 1371413040183 & 370416938652
3. Purpose of development (residential, commercial, industrial, institutional,etc.) RESIDENTIAL
4. Approximate soil disturbance date 1 11 /1 /21
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 17.00
6. Has an erosion and sedimentation control been filed? r Yes F No FX_ Attached
7. If you have an Erosion Control billing account, would you like this to be billed? (— yes FX_ No
Account Number NA
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name I' aSQ,,1 (Vi `4f i ti r E-mail address I J a.5ovi 0m i'55iG" prop. c o�+
Telephone 9$0. f20• z 2 d0 Cell # F;T,0� 3,�-7, jb2,�5 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name HICKORY TOWNHOMES, LLC Telephone [phone] Fax #
Current Mailing Address I5800 OLD PINEVILLE ROAD - SUITE 201
City CHARLOTTE State INC Zip 28217
Current Street Address
City State Zip
10. Deed Book No. 3687 Page No. 1162 / 1166
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 attached sheet):
Name I HICKORY TOWN HOMES, LLC
Current Mailing Address
5800 OLD PINEVILLE ROAD
E-mail address [e-mail]
City CHARLOTTE State NC Zip [28217

Current Street Address
City State Zip
Telephone 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 NA E-mail address
Current Mailing Address
City I State I Zip
Current Street Address
City State Zip
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 E-mail address
Current Mailing Address
City I State I Zip
Current Street Address
City State Zip
Telephone 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.
1 ` _ -jG_SoYI Me-4ry-l'N"
Type or Print Name , ,
le V-
Title of Authority
9/zo�2i
Date
I, U SaLn 4—ic1C� _ , a Notary Public of the County of ` t State of North
Carolina, hereby certify that) C c" LScfo 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 2-
Seal RM
day of , 202.1
Notary
My Commission expires C
Print Form