NCC242924_FRO Submitted_20240920

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 'Cobblestone(Lots 12, 16, 18, 18A,19, 19A,20,20A,23,23A,24,24A,25&25A)
2. PIN or 911 Address 'Cobblefield Lane,Denver,NC 28037-7843
3. Purpose of development(residential, commercial, industrial, institutional,etc.)IResidential
4. Approximate soil disturbance date 105/2024
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 110.24
6. Has an erosion and sedimentation control been filed? Ix Yes I— No E Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes r No
Account Number I
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name !Henry Kirchner E-mail address 1Hry.K1rchr@centuommte5c0m
Telephone [phone] Cell # 1704-600-8456 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name 'Century Communities Southeast, LLC Telephone I Fax# I
Current Mailing Address 17401 Carmel Executive Park Drive
City 'Charlotte State INC Zip 128226
Current Street Address 17401 Carmel Executive Park Drive
City 'Charlotte State INC Zip 128226
10. Deed Book No. 103856 Page No. j0477-0479
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 'Century Communities Southeast,LLC E-mail address [e-mail]
Current Mailing Address 17401 Carmel Executive Park Drive
City !Charlotte State INC Zip J28226

Current Street Address 17401 Carmel Executive Park Drive
City (Charlotte State INC Zip 128226
Telephone I704-754-5460 Fax# I
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 I
City I State ( Zip
Current Street Address I
City I State I Zip
Telephone I 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 I E-mail address I
Current Mailing Address
City I State ( Zip
Current Street Address I
City I State I Zip I
Telephone I Fax# I
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.
Andrew Rouzer Division President
Type o rint N me Title of Authority
6/13/2024
Signature Date
I, . 1 udl L. 1'I'nd etn , a Notary Public of the County of eQciOn State of North
Carolina, hereby certify tl,a,,,,,,I,p(\(e j) r appeared personally before me this day and being duly
sworn acknowledge tj0t iy0 t eAticv was executed by him.
Witness my handjirottysAOjj P° I?j day of ,)Lkfl e ,2029
Seal C (A
• Not ry• ___ ` ��(s'�.`'�� My Commission expires �D. 12, TM
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