NCC221532_FRO Submitted_20220420

PLAN REVIEN18FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNT' 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 lWaterstone
2. PIN or 911 Address 460717000201
3. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
4. Approximate soil disturbance date May 1, 2022
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 10.8
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? r Yes R No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name jEd Estridge E-mail address [e-mail]
Telephone �— Cell # 704-975-9560 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name IBlackstone Development Group LLC Telephone [phone] Fax #
Current Mailing Address I11615 Rosewood St
City Leawood State KS Zip 66206
Current Street Address ISame
City I State Zip
10. Deed Book No. 3388 Page No. 817
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 Sinacori Builders LLC E-mail address [e-mail]
Current Mailing Address 10100 Park Cedar Dr Ste 166
City Charlotte State NC Zip 28210

Current Street Address 19325 Center Lake Drive Ste 160
City Charlotte �State NC Zip 28216
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
Current Mailing Address
City State
Current Street Address
City I State
E-mail address
Zip I
Zip F
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 State Zip
Current Street Address
City State I 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
provorrected information should there be any change in the information provided herein.
,a— 01 IA-"U t�2�
Type or Pr me Title of Authority
i a— 1
Signature Date
a Notary Public of the County of State of North
Carolina, hereby certify that `Aappearled personally before ie this day and being duly
sworn acknowledge that the above form was executed by hi .
Witness my hand and �gj*Wiil,*s % day of � ,n S— , 20)
` �, A- IVea
Seal �
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My Commission expires
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