NCC240473_FRO Submitted_20240219

'-t, SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
i NATURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
R URCGS
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 Lo & F1ac' -Wi� :• VA Atilt,
1. Project Name
2. Location of land-disturbing activity: Latitude 35.Ltk.12 Longitude --80. 1Q5
Parcel Identification Number(PIN) YYIv 1ii 1 Watershed Area CL1*L J..aba' V Cc 31CZ1
Highway/Street Address $ ttl
}groacara . /De.r'vet, 1�C 2 l) -1 rt
Asp 31g28
3. Approximate date land-disturbing activity will commence: 36544
T7
4. Purpose of development(residential,commercial, industrial, institutional, etc.): K,es 1A X .ttt
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): t,3i4
�06. Amount of fee enclosed: $ ' iW d .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 I
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1--034x1 K-A E-mail Address 1 Oaa.rl ridclt L b 1@ ra'al.co,/Vl
Telephone 704-US1 0)9 3 Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
'Mte. Cusfium PCPAto s, L-(G 7o-- (oSI-0 t g3
Name 22 Lan
Telephone Fax Number
1�
P.D. La
Current Mailing Address Current Street Address
02iNver QC at 31
City 32,
1
1 State Zip City State Zip
10. Deed Book No 3252 Page No. (PUP most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name Telephone Fait Number
Current Mailing Address urrent Street Address
City State Zip City State Zip

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R wires 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):
aC11.e Cuc-\-Dm IoicvAeS,�c c, 10 ddl.Q el 0 tritaji l . c MLA
Name E-ral Address
Pic. GoC�1
Current Mailing Address Current Street Address
Denver NC 28 )3'7
City State Zip City State Zip
Telephone ID�1'iPS)-OI 13 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-mai ress
Current Mailing Address Current Street Address
City State Zip City State
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:
kkharri l oc .n ddk \ anr'I ddL 8� @ . COAX
Name of Registered Ag nt E ail Address
525 5. ('.htxztl - Vn►t 310R
Current Mailing Address Current Street Address
G�ar►o�te ►� 0162
City State Zip City State Zip
Telephone TN'(QS) r OIg3 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 g Firm or he sultant E-mai ess
Current Mailing Address City State i
Individual contact person(type or print) Telephone Fax Number

z° SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Rc ou65 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:
i dd It Cost". i*t n s, Lit. Lo c iu Fdd l c,
Name of Person or Firm Name of Person or Firm
Pb 604. ((nl
Current Mailing Address Current Street Address
Dover lvC- 28-o3-)
City State Zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone 1o1-1- 01at3 Telephone
Fax Number 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 his agents to enter on the land in question in connection and/or related to this permit.
i ft; Q-IA13 (�(i&ti►.I manLu (
Te or print name Title r Authority
Signature Date
I, fDaYliit 1e 1?ijdi& lf , a Notary Public of the County of Una J/'l
State of North Carolina, hereby certify that fit an 2idQ(b appeared personally before
me this day and being duly sworn acknowledged tat the above for r - executed by him.
Witness my hand and notarial seal,this j Le day of ' IrU L t , 12._
T. R0t/,� ��!✓,/�% i/,���
........
War.. i 4. \AOTA 9), ••.fir = My commission expires 6 1i3/26,260
2•.