NCC215769_FRO Submitted_20211020

Print Form
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R soia;' 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
I . Project Name Magnolia Ridge Subdivision
2. Location of land -disturbing activity: Latitude 35031'56"N Longitude 81°06'53"W
Parcel Identification Number (PIN) 3675052140 Watershed Area N/A
Highway/Street Address Lee Lawing Rd., Ironton, NC 28092
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.45 Ac.
6. Amount of fee enclosed: $ 3000 . 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 Bobby Tucker E-mail Address bobbyna,buildwithucg.com
Telephone [phone] Cell # 828-455-9067 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
United Contracting Group Inc.
Name
7480 Waterside Loop Rd., Suite 2C
Current Mailing Address
704-736-2051
Telephone
704-736-4957
�ax Number
7480 Waterside Loop Rd., Suite 2C
Current Street Address
Denver NC 28037 Denver
City
State Zip City
NC
State
28037
Zip
10. Deed Book No. 2983 Page No. 631 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Current Mailing Address
City
Telephone Fax Number
Current Street Address
State Zip City
State
WE

_A; SOIL EROSION and SEDIMENTATION CONTROL
MWWLincoln County Natural Resources Department
RA� 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RRC[5
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):
United Contracting Group Inc. bobbv(abuildwithucg.com
Name E-mail Address
7480 Waterside Loop Rd., Suite 2C 7480 Waterside Loop Rd., Suite 2C
Current Mailing Address
Denver NC 28037
City State Zip
Telephone [phone]
Current Street Address
Denver NC 28037
City State Zip
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
Teleph
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
WE
(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:
Mitch Latham [e-mail]
Engineering Firm or other consultant E-mail Address
16507-A Northcross Dr. Huntersville NC 28078
Current Mailing Address City State Zip
Mitch Latham 704-895-8484
Individual contact person (type or print) Telephone Fax Number

4N Cp%
SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
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:
United Contracting Group Inc.
Name of Person or Firm Name of Person or Firm
7480 Waterside Loop Rd., Suite 2C
Current Mailing Address Current Street Address
Denver NC 28037 _
City State Zip City
State Zip
Bobby Tucker
Individual contact person (type or print) Individual contact person (type or print)
Telephone [phone] Telephon
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 attom ey- 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.
Bobbv Tucker \'ice President
Type or print name Title or Authority /
Signature Dat—
I, a Notary Public of the County of L-4 Lfj V 1
State of North Carolina, hereby certify that .0 ppeared personally before
me this day and being duly sworn acknowledged that the ab a form was execu ed by im.
Witness my hand and notarial seal, this day of ,
My commission expires