NCC223583_FRO Submitted_20221019

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, place N/A in the blank)
PART A
1. Job Name Lakeside Pointe Subdivision
2. PIN or 911 address 460606392089
3. Purpose of development (residential, commercial, industrial, institutional, etc.) Residentail/commercial
mixed use
4. Approximate soil disturbance date June 2022
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 74.04 Ac.
6. Has an erosion and sedimentation control plan been filed? Yes No Attached _V _
7. If you have an Erosion Control billing account, would you like this to be billed? Yes_ No '�/
Account number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Brian Amos E-mail address [e-mail]
Telephone [phone] Cell #_ [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Brookfield Holdings Shiv_esLLC r [phone] N/A
Name Telephone Fax Number
250 Vesey Str FL 15
Current Mailing Address Current Street Address
New York NY 10281-1065
City State Zip City State Zip
10. Deed Book No. 3700 Page No. 0291
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):
Beechwood Shvies LLC [e-mail]
Name E-mail Address
7621 Little Avenue Suite 111
Current Mailing Address Current Street Address
Charlotte NC 28226
City State Zip City State Zip
_(704) 631-9838
Telephone 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
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Telephone
Fax Number
2. (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:
Bob Kardos
[e-mail]
Name of Registered Agent
E-mail Address
7621 Little Avenue Suite 111
Current Mailing Address
Current Street Address
Charlotte NC 28226
City State Zip
City State Zip
_�704) 582-3989
NIA
Telephone
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 be
any change in the information provided herein.
Bob Kardos Regional President, Carolinas
Type or printkanV Title or Authority
— .. — [�'X t 4 � Vol
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledge that the above form was executed by him.
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