NCC233726_FRO Submitted_20231219

Print Form
C110 SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
itrNn ras 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / 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 N/A in the blank.)
Part A
1. Project Name Denver NC-16 MOB
2. Location of land-disturbing activity: Latitude 35.451761 Longitude-80.995748
Parcel Identification Number(PIN)4602558328&4602555288 Watershed Area Catawba
Highway/Street Address Eastern Medical Drive, Denver, NC 28037
3. Approximate date land-disturbing activity will commence:May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.50 Acres
6. Amount of fee enclosed: $1000 .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 X
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nikolaus Lischerong E-mail Address [e-mail]
Telephone [phone] Cell# 864-590-6478 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Denver Dirt, LLC 864-590-6478
Name Telephone Fax Number
1420 E 7th Street Suite 100 1420 E 7th Street Suite 100
Current Mailing Address Current Street Address
Charlotte NC 28204 Charlotte NC 28204
City State Zip City State Zip
10. Deed Book No.3219 Page No.569 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

° SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
" ,res, 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL b Si'ONSIBILITY I OWNERSHIP FVIM
Part B
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):
Nikolaus Lischerong [e-mail]
Name E-mail Address
6256 Sharon Hills Road 6256 Sharon Hills Rd
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City State Zip City State Zip
864-590-6478
Telephone 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 runic,
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:
V3 Southeast [e-mail]
Engineering Firm or other consultant E-mail Address
2923 S Tryon Street, Suite 320 Charlotte NC 28203
Current Mailing Address City State Zip
David Klausman 803-513-4734 N/A
Individual contact person(type or print) Telephone Fax Number

N ( (--(
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Resilat`ts, 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
Ferrara-Buist
Name of Person or Firm Name of Person or Firm
4184 Dobys Bridge Road, #100
Current Mailing Address Current Street Address
Indian Land SC 29707
City State Zip City State Zip
David Buist
Individual contact person (type or print) Individual contact person (type or print)
Telephone [phone] Telephone
Fax Number N/A 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 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 hir rigent'.to enter on the land in question in connection and/or related to this permit.
4./Fi A
Type or print nm ' Title or Authority
/A 7/2 3
Signat a Date
I, t U ►vY\ T�(l1V �v 1" , a Notary Public of the County of CcL, y-LAS
State of North Carolina, hereby certify that N ; 10101,{A,j LISI1A-elKO(101 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 1-1 day of JNn
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