NCC224146_FRO Submitted_20221219

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SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
• 115 West Main Street, Lincolnton, NC 28092 704.736-0501 Fax [phone]
No person may initiate any land disturbing activity on one or more acres as covered by the Act before this form and an acceptab'e
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 a mail and/or fax information unavatlable, place N/A in the blank )
Part A
l . Project NameMdtown Business Park - Lot 5
2 Location of land -disturbing activity Latitude35.444717 Longitude•81 270415
Parcel Identification Number (PIN)3622348532 Watershed AreaWS-IV PA
Highway/Street AddressMidtown Dr `
3 Approximate date land -disturbing activity will commence November 18 2022
4 Purpose of development (residential, commercial, industrial, institutional, etc) Industrial
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas) 0.70
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 ceding 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 53.800 GO).
7 Has an erosion and sediment oontrot plan been filed? YesX No EndosedX
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity.
Namelnor Shiper _E-mail AddressigorAceboffice cam _
Telephone[phone] Cell #
Fax #
9- Landowner(s) of Record (attach accompanied page to list additional owners)
CAROLINA ELITE BUILDERS LLC 919-274-3200
Name Telephone Fax Number
205 S ACADEMY STREET 205 S ACADEMY STREET
Current Matting Address Current Street Address
LINCOLNTON NC 2a092 LINCOLNTON NC 28C92
City State Zip City State Zip
10 peed Book No 3149 Page Na 586 most recently filed in Lincoln County Register of Doec;s
11 Future Lardowner(s) if applicable. (attach accompanied page to list additional owners)
Name
Current fviailing Address
City State Zip
Telephone Fax Number
Current Street Address
City State Zip

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
hP
,:1' 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax [phone]`,T ,. -. 'i ..
FINANCIAL RESPONSIBILITY l OWNERSHIP rORM
Part B,
1. Person(s) or firm(s) who are financially responsible for the land disturbing activity (Provide a comprehensive
list of ali responsible parties an an attached sheet).
Igor Shiper
Name
205 S Academy St
Current Mailing Address
Lincolnton NC 28092
City State Zip
Telephone [phone]
igor a@7ceboffice com
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 Mailing 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 E-mail Address
Current Mailing Address
Current Street Address
City 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 Firm or other consultant E-mail Address
Current Mailing Address City State Zip
Indk ideal contact person I type or print) Telephone I'ae tiwmb' r

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Linco€nton, NC 28092 704.736.8501 Fax' 704-736-6 04
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d) Contractors andfor 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 Mailing Address Curtent Street Address
Lincolnton 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 Financially
Responsible Person). I agree to provide corrected information should thereby any change in the information provided
herein and any other associated documents. I understand that all documents that are assaciated 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 andlor related to this permit.
Igor Shiper
Owner
Type or crint owe Title or Authority
S re Date
I _ Su Swn 92 , Gear a Notary Public of the County of U n Cn (_
State of North Carolina, hereby certify that 1 C)or S)'`' Pr-r appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him
Witness my hand and notarial seal, this 1day of �JW-e-ty.A7er . 20 �3
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