NCC230143_FRO Submitted_20230207

° N: a SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 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 NIA in the blank.)
Part A
1. Project Name L o:t5 @ Fa" Sones Y,,o V, ?r opp=
2. Location of land -disturbing activity: Latitude �5• ��� Longitude `-01 • OO$
Parcel Identification Number (PIN) PAVk+ipLO Watershed Area R iVCr
Highway/Street Address T�ZKbY-0-5-Rao _ _Der)vCc ., N G 2Bb3 71
3. Approximate date land -disturbing activity will commence: _. A6h
4. Purpose of development (residential, commercial, industrial, institutional, etc.): }��StL�2r1�!1 GA
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ _ 7'7dp• 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? Yes No Enclosed V
8. Local appointed person to contact should erosion and sediment control issuesarise during land -disturbing activity:
Name %AtO (t-L E-mail Address a.c` �aw A&V i V--GS 12 0A Ail ca-
Telephone Cell #, 704.562.60 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
e)Qe &�� u ffiP1e)
Name Telephone
Current Mailing Address Current Street Address
City State Zip City
State
Fax Number
Zip
Se S C
10. Deed Book No Page No.b>`most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Telephone
Current Mailing Address Current Street Address
City State Zip City State
Fax Number
Zip

L14 c SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
rtc - 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY/ OWNERSHIP FORM
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):
0LI PCo�c,ck��5 LLG a�tn day�d�DvFrr@5��ri�``��•o •
Name E-mail Address
'Ld a `"f ' c
Current Mailing Address Current Street Address
%_ N J.- Nc- T9037
City State Zip City State Zip
Telephone . G( 6 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
Current Mailing Address
E-mail 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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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
Individual contact person (type or print) Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
_ Lincoln County Natural Resources Department
RLSrOUR r& 115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: [phone]
�W ,ems
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
kji! IPRU{P o L1,61
Name of Person or Firm
Name of Person or Firm
"`k CU`rAM WAY
Current Mailing Address Current Street Address
City State Zip
City
State Zip
L1535 q t t-t.
Individual contact person (type or print) Individual contact person (type or print)
Telephone
Fax Number
OL43n' 667.E Telephone
Fax Num
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 by any change in the information 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
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.
Type or print name Title or Authority
Signature
1 /5tS. _
Date
I. fLudj�,5dl , a Notary Public of the County of 1 1 n ( 6 ) a
State of North Carolina, hereby certify that [ b 141,11 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 day of 20
�� Vx-E4T.'
Not
NOTARY M commission expires 24Z
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Addendum to Financial Responsibility/Ownership Form
Part 9: Landowners of Record
Parcel ID
Lot Number
Owner of Record
Mailing Address
113 North Center Street
90334
4
REDHEAD LAND &
Suite 103
DEVELOPMENT LLC
Statesville, NC 28677
113 North Center Street
90335
5
REDHEAD LAND &
Suite 103
DEVELOPMENT LLC
Statesville, NC 28677
113 North Center Street
90336
6
REDHEAD LAND &
Suite 103
DEVELOPMENT LLC
Statesville, INC 28677
ADAM DAVID HOMES
2004 Captains Way
90332
2
LLC
Denver, NC 28037
KOLI PROPERTIES
2004 Captains Way
90331
1
LLC
Denver, NC 28037
KOLI PROPERTIES
2004 Captains Way
104641
1A
LLC
Denver, NC 28037
KOLI PROPERTIES
2004 Captains Way
104642
113
LLC
Denver, NC 28037
Part 10: Deed Book No. and Page No.
Parcel ID
Lot Number
Deed Book No.
Page No.
90334
4
3163
305
90335
5
3147
449
90336
6
3147
449
90332
2
3147
358
90331
1
3147
329
104641
1A
3147
329
104642
1B
3147
329