NCC233146_FRO Submitted_20231023

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,please N/A in the blank)
PART A
1. Job Name ROCKHAVEN RESIDENTIAL SUBDIVISION
2. PIN or 911 Address 3753-04-93-4193&3753-04-92-4302
3. Purpose of development(residential, commercial, industrial, institutional,etc.)I RESIDENTIAL
4. Approximate soil disturbance date MAY 2021
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) I 17 ACRES
6. Has an erosion and sedimentation control been filed? r Yes r No 17 Attached
7. If you have an Erosion Control billing account,would you like this to be billed? r Yes IF No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name CODY SIPE E-mail address [e-mail]
Telephone Cell # [phone] Fax#
9. Landowner(s) of Record(attach accompanied page to list additional owners)
Name I IMRIE LLC Telephone [phone] Fax#
Current Mailing Address 400 N CHURCH ST UNIT 706
City CHARLOTTE State NC Zip 28202
Current Street Address 400 N CHURCH ST UNIT 706
City CHARLOTTE State NC Zip 28202
10. Deed Book No. 3529 Page No. 0008
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 attached sheet):
Name IMRIE LLC E-mail address [e-mail]
Current Mailing Address 400 N CHURCH ST UNIT 706
City CHARLOTTE State NC Zip 28202

Current Street Address 400 N CHURCH ST UNIT 706
City CHARLOTTE State NC Zip 28202
Telephone I [phone] Fax #
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 I E-mail address I
Current Mailing Address
City I State I Zip I
Current Street Address
City I State I Zip I
Telephone I Fax#
2. (b) If the financially responsible party is a Partnership or other person engaging in business under 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 E-mail address I
Current Mailing Address
City State I Zip I
Current Street Address
City I State I Zip I
Telephone Fax#
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.
LYi✓ J7 7 E (A./IS Oc.c.)n�
Type or Print e Title of Authority
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Signature Date
I,-7.fi i R10_lH 3. VU )EQ_ ,a Notary Public of the County of AG e,K LGg 43t9 R State of North
Carolina,hereby certify that ti-`/c tt'l M T C 1-G%Ni S appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
Witness my hand and notary seal,this ta-TH day of 1c rz.t I- ,20 a 1,
Seal Patricia B. Kunder �C�
NOTARY PUBLIC Notary
Mecklenburg County My Commission expires I - a-s
North Carolina
My Commission Expires 9/14/2025 Print Form