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HomeMy WebLinkAboutNCC220722_FRO Submitted_2022021111N c k SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department NATURAL 115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: 704-736-8504 RESOURC 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 Ventosa at Catawba Springs - Phase 1 2. Location of land -disturbing activity: Latitude 35.490 N Longitude 81.025 W Parcel Identification Number (PIN) 3693783930, 3693790607, 3694801831 Watershed Area CATAWBA Highway/Street Address Kidville Rd. Catawba Springs, NC 28037 3. Approximate date land -disturbing activity will commence: 02/20/21 4. Purpose of development (residential, commercial, industrial, institutional, etc.): SF Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.92 AC - Phase 1 6. Amount of fee enclosed: $ 400 . 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 X No Enclosed YES 8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity: Name David Clark Jr. E-mail Address davidcjr@mac.com Telephone 980 721-1519 Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Ventosa LLC 980 721-1519 Name Telephone Fax Number 218 West Main Street Current Mailing Address Current Street Address Lincolnton NC 28092 City State Zip City State Zip 10. Deed Book No 2640 Page No. 376 most recently filed in Lincoln County Register of Deeds. 11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners): Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip *NATUKAL SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504 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): David Clark Jr. (Ventosa LLC) davidcjr@mac.com Name E-mail Address 218 West Main Street Current Mailing Address Lincolnton NC 28092 Current Street Address City State Zip City State Zip Telephone 980 721-1519 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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: Bloc Design dklausman@bloc-nc.com Engineering Firm or other consultant E-mail Address 2923 S. Tryon St. Suite 320 Charlotte NC 28203 Current Mailing Address City State Zip David S. Klausman, P.E. 803 513-4734 Individual contact person (type or print) Telephone Fax Number y SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department Rc"si 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504 FINANCIAL RESPONSIBILITY / OWNERSHIP FORM (d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity: Name of Person or Firm Name of Person or Firm po 0 1 Current Mailing Address Q a 2, City State Zip Current Street Address State Zip ALZ`Y -DEAL- Individual contact person (type or print) Individual contact person (type or print) Telephone C7014735- 1957 Telephone Fax Number City 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. AV E-D Z, L. A 2tL ��. M A W AG�� Type� Title or A thor S z1 Signature Date ------------------------------------------------ - - ------------------------------------- a Notary Public of the County of State of North Carolina, hereby certify that 1� QU"p \\t;i,,,t)k '�-. k -- _ appeared personally before me this day and being duly sworn acknowledged that the above for- m was executed by him. Witness my hand and notarial seal, this Sn _day of 20 Zl_\ WANDA B BAKER Notary OMTARY PUBLIC \ CATAWBA COUNTY My commission STATE OF NORTH CAROLINA