NCC224144_FRO Submitted_20221219

Print Fnrm
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural ReSources Department
115 West Main Street, Lincolnton, NC 28092 704.736-8501 Fax: [phone]
FINANCIAL. RESPONSIBII-ITY I 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 MA in the blank )
Par/ A
I . Project NameMidiown Business Park -Lot 4 artt ` (��4 Zu
2. Location of land -disturbing actvity. Latdude35.444730 Longitude-81 270947
Parcel Identification Number (PIN)3622346595 Watershed AreaM-IV PA
Highway/Street AddressMidtown Or
3 Approximate date land -disturbing activity will commence November 18, 2022
4 Purpose of development (resident4, commercial, industrial, institutional, etc,):industrial
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas)-0 50
6 Amount of fee enclosed: $200 . 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 fee 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? YesX No EnclosedX
8 Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Narnelgu Shaper E-mail Add ressigor2ceboffice.com
Telephone[phone] Celt # Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
CAROLINA ELITE BUILDERS LLC 919-274-320D
Name Telephone Fax Number
205 S ACADEMY STREET 205 S ACADEMY STREET
Current Marling Address Current Street Address
LINCOLNTON NC 28092 LiNCOLNTON NC 28092
City State Zip City State Zip
10 Deed Book No 3149 Page No 586 most recently filed in Lincoln County Register of Deeds
11 Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Current Mailing Address
City State
Telephone Fax Number
Current Street Address
Zip City
State Zip

w SOIL EROSION and SEDIMENTATION CONTROL
4:p.1 Lincoln County Natural Resources Department
i; 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY t OWNERSHIP FORM
Part: B
1 Person(s) or firm(s) who are financially responsible for the iand-disturbing activity (Provide a comprehensive
list of all responsible parties on an attached sheet),
Igor Shiper Igor@ceboffice com
Name
205 S Academy St
Current Niading Address
Lincolnton NC 28092
City State Zip
Telephone[phone]
E-mail Address
205 S Academy St
Current Street Address
Lincolnton NC 28092
City State Zip
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 Marling Address Current Street Address
City State Zip City State Zip
Telephone Fax Number,
(b) if the Financially Responsil 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 Ccrporaticn
give name and street address of the Registered Agent
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City W State Zip City State Zip
Telephone Fax Number
(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 Firth or other consultant E-mail Address
Current Mailing Address City State Zip
ini}i4 idual contact permit (type or print) — — 1'iAephone tax 'Numbs

SOIL EROSION and SEDIMENTATION CONTROL
Y Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, NC 28092 704-736.8501 Fax 704-736-K104
FINANCIAL RESPONSIBILITY I OWNERSHIP FORM
(d) Ceniractors and?or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity
Igor Shiper Igor Shiper
Name of Person or Firm Name of Person or Firm
205 S Academy St 205 S Academy St
Current (Nailing Address Current Street Address
Lincointon NC 28092 Lincolnton NC 28092
City State zip City State zip
Igor Shiper
Individual contact person (type or print) Individual contact person (type or print)
Telephone[phone] Telephone[phone]
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 Firancially
Responsible Person). I agree to provide corrected information should there by any change in the =.nfermaticn 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
Igor Shiper
Type ort rin me
�gnature
J ' ScLrn 9. +ems,- E
Owner
Title or Authority
Date
a Notary Public of the County of L 4 h Cc) Ii
State of North Carolina, hereby certify that __ ti5Cr Shr pGr" appeared personaliy before
me this day and being duly sworn acknowledged that the above form was executed by him
1-h
Witness my hand and notarial seal. this day of _NoUCM bW _ , 243--�-
a
My commission expires Nadelir6cir Ji, olo?')