NCC221643_FRO Submitted_20220428

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 Lo_Vt S LLG:_
2. PIN or 911 Address
s .ic;rS F�.a 0C2gw�3
3. Purpose of development (residential, commercial, industrial, institutional,etc.)l
4. Approximate soil disturbance date ? f v pzA:`� n CA9CA..A-k <j
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) --,s
6. Has an erosion and sedimentation control been filed? 1' Yes P(No f Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes No
Account Number �—
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name I Gt a, a_c;� K_Q..V E-mail address g P l-tsACAAS't 4W-lX6,XAC S ® aok c--N
Telephone 1 —16 c y y b b k1 Z 1 Cell # D y(A vb 0 7- t Fax # ------
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name I La_N(..2 �Jol ,ud. n 1, Ctc-� ��*�` Telephone Fl-z,) (.o -7 _� givi Fax # F_
'iLei.-'ta 5 L�'C-
Current Mailing Address I '1 D 20\ "wz n L
City I SK,C.u.•�¢�.''.et State >J C Zip 2�ss R
Current Street Addresses '--6
City F_ State � Zip
10. Deed Book No. 3 �v g $ Page No.
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 �CC� 1�V\ ,LA r''r'z r E-mail address
Current Mailing Address U ?-,I —_LWri'S a ry Q.d
City I ���M�'`'���Q�'� State —C Zip 2 "Z ss 8

Current Street Address sv�, }-t a &-b
City I State Zip F
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 E-mail address
Current Mailing Address
City I State F Zip F
Current Street Address
City I State F 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 LO-AA-e 1-�­ .�m E-mail address ��, j
� L ti�1 d. \S � L
Current Mailing Address I "t 2 e>\ —3t': •S &,,^ 'R-.4
City S v, j-� i-�t25 . 2 \d State 1J C. Zip
Z i S g —
Current Street Address �t� Q
City I State Zip
Telephone I 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.
KE vr.w T- GAAT-c 4
Tyke or Print Q
Signature
111 RA/Ae-eR
Title of Au ority
lila5
Da e
t I, K6h]... (� f6 17 , a Notary Public of the County of dddj d State of North
Carolina, hereby certify that Mlri (�rfgr appeared personally before me this day and being duly
sworn acknowledge that the above fonn was executed by him.
Witness my hand and notarY� day of &/
Seal `�.�`0�0, W Hq��0�
,q p1OTAR Y 2
MY
s G PUBLIC 2
Notary�- ' 2/�3/27
My Commission expires_
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