NCC221177_FRO Submitted_20220401

w SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
e 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY f 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 and/or fax information unavailable, place NIA in the blank.)
Part A
I. Project Name L
2 Location of tand-disturbing activity. titude 35 • S Longitude O'17
Parcel Identification Nu er (PIN) Watershed Are
Highway/Street Address rwNC 2_90Ai
3. Approximate date land -disturbing activity will commence: 5
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Re! to ` QL
5. Total acreage disturbed or uncovered ncludin off -site borrow and waste areas): o ..
,v �r vrGvsly
6. Amount of fee enclosed: $ jpp �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 tee 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 $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No _ Enclosed
8. Local appointed person two contact should erosion and sediment control issues arise during land -disturbing activity:
Name to ,1 _YAS E-mOAddress� ACh$ tctrrC(erfft%rtMa4
Telephone
Cell#-709JQ.9�1_3 Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners):
btIl"l4ef Bviir , Lu.
Name J Telephone
F-v1 box 433
Current Mailing Address Current Street Address
3
City State Zip City
337
Fax Number
Slate Zip
10, Deed Book No 2UC2LJ 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 Fax Number
Current Mailing Address Current Street Address
City
State Zip City
State
Zip

} - SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, (-incolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY l 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):
Deft pw <r $tuticier5 LLC e- k ,L- erbt,-, >�is � RrrtuA cvrtt
Name f Email Address 0 L)
a51 "Opewell C�rusrc t Erj
Current Mailing Address Current Street Address
CAaWbc. NC 7-8bo9
City State Zip City State Zip
Telephone Z 0 N• 9 0 L NO O 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
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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State 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:
Engineering Firm or other consultant
Current Mailing Address City
Individual contact person (type or print)
E-mail Address
State Zip
Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
-,L 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
�e11i,r`g er Butld�r5� LLC CcLmr,,xi c btk(A �{—
Name of Pers4 or Firm Name of Person or Firm
`i S l Hypcw{ 11 Gin Rd
Current Mailing Address
Current Street Address
CuAW 01 N C 2-wog _
City Slate Zip City
State Zip
Camynt e bc! ivv-q .r
Individual contact person (type c rint) Individual contact person (type or print)
Telephone -1 U u( . -10Z ' Y`j 8 3 Telephone
Fax Number
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
C&MMic bffltvL.c.e4 BuAvA5
Type or print name
Signature
0t'DV1eK
Title or Authority
Date
3--io- 2-2.
I, f I I a Notary Public of the County of Ll 000) n
State of North Carolina, hereby certify that l�iaYY1fY}rQ.��'I �I r)Cf r gu ry-is appeared personally before
me this day and being duly sworn acknowledged that the above f6tim was executed by him.
Witness my hand and notarial seal, this I_day of .20 J
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My commission expires r� c�