NCC233786_FRO Submitted_20231221

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORD[NANCES, 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 ICanova Crossing
2.PIN or 911 Address 'County Home Road;#373220929103
3. Purpose of development(residential,commercial,industrial, institutional,etc.)'Residential
4. Approximate soil disturbance date February 15,2024
5.Total acreage disturbed or uncovered(including off-site borrow and waste areas) 12.6
6. Has an erosion and sedimentation control been filed? : r Yes r No [1 Attached
7. If you have an Erosion Control billing account,would you like this to be billed? fl Yes Pe- No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Michael Foess E-mail address [e-mail]
Telephone IN/A Cell# 1704-491-3256 Fax# N/A
9. Landowner(s) of Record(attach accompanied page to list additional owners)
Name(County Home Road,LLC Telephone N/A Fax# IN/A
Current Mailing Address 1375 10th Avenue Drive NE
City 'Hickory State NC Zip 128601-2647
Current Street Address 'same
City State Zip I
10. Deed Book No. 12119 Page No. 1933
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 'Canova Crossing Partners,LLC E-mail address [e-mail]
Current Mailing Address IP°Box 644
City (Cornelius State INC _ Zip 128031

f p.
Current Street Address 115905 Brookway Dr,Suite 4208
City IHuntersville State INC Zip 128078
Telephone [phone] Fax# I N/A
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 I
City I State Zip I
Telephone Fax# I
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 Michael Foess E-mail address [e-mail]
Current Mailing Address IPO Box 644
City IHuntersville State INC Zip 28031
Current Street Address 15905 Brookway Dr,Suite 4208
City IHuntersville State NC Zip 128078
Telephone [phone] Fax# N/A
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.
Allehni / 2S /vim�1 ir) M�vt4 l
Type or Print Nam Title of Adthof
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Signature Date
I, KC`Sei` C,h1 Xe,A1T ,a Notary Public of the County of M(�(,�,,�\O W/9 State of North
Carolina,hereby certify that till(jaa C,\ - Q'(SS 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 a Q day of D CA-M ,1r ,203
Seal KASEY CHARETTE JcJAL1,
Notary Public Notary ii l �� r,
Mecldenburg Co.,North Carolina My Commission expires wvl aV
My Commission Expires May 30,2028 ,J