NCC242305_FRO Submitted_20240730

Print Form
C110 SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NA wrs 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 Sennebogen Expansion
2. Location of land-disturbing activity: Latitude 35°25'12.2"N Longitude-81°01'00.2"W
Parcel Identification Number(PIN)3691941330 Watershed Area None
Highway/Street Address 1957 Sennebogen Trail Stanley, NC 28164
3. Approximate date land-disturbing activity will commence:7/11/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):8.4
6. Amount of fee enclosed: $1,800 .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 Mark Murray E-mail Address [e-mail]
Telephone [phone] Cell# 980-239-8243 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Sennebogen Real Estate LLC 704-347-4910
Name Telephone Fax Number
1957 Sennebogen Trail 1957 Sennebogen Trail
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
City State Zip City State Zip
10. Deed Book No.1838 Page No.694 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
N/A
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

°vN SOIL EROSION and SEDIMENTATION CONTROL
•' Lincoln County Natural Resources Department
•,,a;., 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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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):
Sennebogen Real Estate LLC
Name E-mail Address
1957 Sennebogen Trail 1957 Sennebogen Trail
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
City State Zip City State Zip
Telephone [phone] 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 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:
Constantino Lannes [e-mail]
Name of Registered Agent E-mail Address
1957 Sennebogen Trail 1957 Sennebogen Trail
Current Mailing Address Current Street Address
Stanley, NC 28164 Stanley, NC 28164
City State Zip City State Zip
Telephone [phone] O Fax Number 7011 '3`f - fag
(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:
CES Group Engineers, LLP [e-mail]
Engineering Firm or other consultant E-mail Address
3525 Whitehall Park Drive Suite 150 Charlotte NC 28273
Current Mailing Address City State Zip
Jake Modestow 704.489.1500
Individual contact person (type or print) Telephone Fax Number

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F S IL EROSION and SEDIMENTATili N CONTROL
Lincoln County Natural Resources Department
''^-kkI - 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
S.C. Hondros&Associates, Inc
Name of Person or Firm Name of Person or Firm
PO Box 220456 3309 Washburn Ave.
Current Mailing Address Current Street Address
Charlotte NC 28222 Charlotte NC 28205
City State Zip City State Zip
Mark Murray
Individual contact person(type or print)Individual contact person(type or print)
Telephone [phone] Telephone
Fax Number704-372-1252 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.
Constantino Lannes President&Chief Executive Officer
Type or print name Title or Authority
6/5/2024
Signa Date
I, I3h1(.\ Aukr1 ,a Notary Public of the County of iv12CKhohorC1
State of North Carolina,hereby certify that C.of154-a k inO 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 5-m day of ,ur\_ ,20 21
/
ivea1 � ''/ Notary
11 My commission expires I I`L'LI 2.625
NOTA
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