NCC242837_FRO Submitted_20240916

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 (PIPER CREEK SUBDIVISION-PHASE 1
2. PIN or 911 Address 2228 COLEY FISH POND RD,NEWTON,NC 28658
3. Purpose of development {residential, commercial, industrial, institutional,etc.)RESIDENTIAL
4. Approximate soil disturbance date [JUNE 1,2024
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 111.00
6. Has an erosion and sedimentation control been filed? Yes r No f Attached
7. If you have an Erosion Control billing account, would you like this to be billed? jT Yes P No
Account Number N/A
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name E-mail address I
Telephone Cell# 1 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name Clayton Properties Group Inc. DBA Mungo Homes Telephone Fax #
Current Mailing Address 441 Western Lane
City Irmo State ISC Zip 29063
Current Street Address 441 Western Lane
City Irmo State ISC Zip 129063
10. Deed Book No. 13886 Page No. 1551 &1555
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 Clayton Properties Group Inc. DBA Mungo Homes E-mail address 1marnsmLmgo.c0m
Current Mailing Address 8008 Corporate Center Drive,Suite 201
City Charlotte State INC Zip 128226

Current Street Address 8008 Corporate Center Drive,Suite 201
City Charlotte State NC Zip 28226
Telephone [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 CT Corporation System E-mail address I
Current Mailing Address 128 Liberty Street
City New York State NY Zip 110005
Current Street Address 28 Liberty Street
City New York State NY Zip 10005
Telephone [phone] 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
Current Mailing Address
City State Zip
Current Street Address
City I State Zip
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.
f `or4- jeAl f-A " AJ S��' 1- >.y- eGr'e,4 ry
Type or Print, ame Title of Authority
Signature Date l
I, 0 1 `Y - try , a Notary Public of the County of � State of North
Carolina, hereby certify that appeared p lly before me this day and being duly
sworn acknowledge that the above form was executed by him.
Witness my •-rratar9-seal—t ' day of �,, , 20 1-.19
O'Hagi M. NIc rif
Sea Notary Public *" „
Mecklenburg County N
My Commission Exp Notary
My Commission expires eXS� �l8