NCC231144_FRO Submitted_20230421

69 SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
=fi 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
No person m y initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and edimentation control plan has been completed and approved by the Lincoln County Natural Resources Division. (Please
type or print. f the question is not applicable or the e-mail and/or fax information unavailable,place N/A in the blank.)
PartA
1. Projec Name EROSION CONTROL PLAN FOR LOT 6 BALSOM RIDGE ROAD
2. Locaticn of land-disturbing activity: Latitude 35.5436 Longitude 81.0411
Parcel Identification Number(PIN) 86905 Watershed Area WS-IV-PA
Highw.:y/Street Address Parcel 86905 Lot 6 Balsom Ridge Road, Denver, NC
3. Appro imate date land-disturbing activity will commence: June 1,2023
4. Purpo e of development(residential,commercial, industrial,institutional,etc.):_lndustrial
5. Total a reage disturbed or uncovered (including off-site borrow and waste areas):_DISTURBED AREA: 1.99 AC
6. Amou t of fee enclosed:$ 400.00 .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 a erosion and sediment control plan been filed? Yes x No Enclosed x
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Cerbone E-mail Address [e-mail]_
Telephone [phone] Cell# _(917)797-5895 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
JCPC North Carolina, LLC [phone]
Name Telephone Fax Number
_2645 Old Yorktown Road_ Same
Current Mailing Address Current Street Address
Yorktown Heights, NY 10598
City State Zip City State Zip
10. Deed Book No._3038 Page No. 626 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
Same as Above
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

, SOIL EROSION and SEDIMENTATION CONTROL
l-
v Lincoln County Natural Resources Division
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NATURAL p- 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
Part B
1. Perso (s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of:II responsible parties on an attached sheet):
JCPC North Carolina, LLC [e-mail]
Name E-mail Address
2645 o Id Yorktown Road 2645 Old Yorktown Road
Curre t Mailing Address Current Street Address
Yorkto n Heights, NY 10598 Yorktown Heights, NY 10598
City State Zip City State Zip
Telep one 914-352-6688 Fax Number 914-352-6688
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:
JCPC N.rth Carolina—Patricia Cerbone [e-mail]
Name E-mail Address
1258 N. C 16 Business HWY 1258 N. NC 16 Business HWY
Current ailing Address Current Street Address
Denver, C 28037 _ Denver,NC 28037
City State Zip City State Zip
Telepho e 914-352-6688 Fax Number 914-352-6688
(b)If the inancially Responsible Party is a Partnership or other person engaging in business under an assumed name,
attac a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give ame and street address of the Registered Agent:
Name of -egistered Agent E-mail Address
Current ailing Address Current Street Address
City State Zip City State Zip
Telephon- Fax Number
(c)In ord:r to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist n providing any necessary information regarding the plan and its preparation:
_Swartz Design&Engineering, PLLC [e-mail]
Engineeri g Firm or other consultant E-mail Address
58' B and T Lane,Taylorsville,NC 28681
Current ailing Address City State Zip
Jeff S artz, PE 828-632-0499
Individua contact person(type or print) Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
NATU,R 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax:[phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Co tractors:and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
-' C &C 1 i€ J c 'pC...1U oc-1--QA �'. v°rrd rr
Name of Person or Firm Name of Person or Firm
Current Mailing Addre s Current Street Address
*CYIClaAt 1\3 NEE t- f t.:s\I
City State Zip City State Zip
Individual contact person(type or print) Individual contact person (type or print)
Telephone_(it`'�. Z Telephone �i 1 � `j c e.I I,
Fax Number'( 3 2—efa�x 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 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
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.
RI, NO(- ecvarie LLc.
John Cerbone C 1,e;eiii -1 e, Rresident/CEO
Type or print na Title or Authority
Signature Date
I, -4e4'► fl � cJ ,a Notary Public of the County of `1� ,� ,�Qd
State of ';hereby certify that () Y C z__ appeared personally before
me this day and being duly sworn acknowledged��yy that the above form was executed by him.
Witness my hand and notarial seal,this 11Tr�day of ,20 l
Notary
Seal
My commission expires a 7 Q-C)
Denise Betz
NOTARY PUBLIC-STATE OF NEW YORK
Registration No.01 BE6236767
Qualified in Dutchess County
Commission Expires March 7,20