NCC220921_FRO Submitted_20220301

ftoA- vl --ZaZz - .3 5ybtl
PLAN REVIEWIFINANCIAL 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 f �1C�c.�C.s}Ong, 66 �
y 45 - Uri+ loo l - jooL9b�l I0(6L- o3S
2. PIN or 911 Address (o O-7 O tl -7 U -71 y
3. Purpose of development (residential, commercial, industrial, institutional,etc.) 'u, n+ k "i
4. Approximate soil disturbance date T0_(\'j01;, 4_�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) I $.. 31
6, Has an erosion and sedimentation control been filed? r Yes r No 7V Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes F1 No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name & 20rq e— 1 [ t+-ke Ckl c a E-mail address
Telephone -7 ()q - U __-7 3^73 Cell # I ;A- 1-t& Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name 6 6 L � �o c L(, C_ Telephone Fax #
Current Mailing Address i all D C) e-���
City State ziple 3.1 -
Current Street Address
City State Zip
10. Deed Book No. 1 .�6 S 11 1 Page No. I 0a)_
PART B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible pasties on attached sheet):
Name 1), v _ 40 �+v a ) � �_(_ - E-mail address
Current Mailing Address IR09S A f rp W r' 1 0(4 e BW O
City C h� {fit} } State I JJ'___ Zip t ­7 3

Current Street Address
City State I Zip
Telephone 1 —7 U 4 — (a 0�0 __ -1 3 -� 3 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 C' .T �� E-mail address 4 (,VXo C C+-O-of V can ctiy C • (_aVV)
Current Mailing Address ito
City t�e it� �� State j.1 L
Zip j:i (v G
Current Street Address
City State
Zip
Telephone Qrl �_ l - -�� ' y 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 F 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 sho?If there be any change in the information provided herein.
�edl' &d I)YO nee e l-
Type nt Na Title of Authority
1.2 Z q �
Signa Date
I, Rach-el A Ct_l- h ✓i F -CC_L_lrS , a Notary Public of the County of C� State of North
Carolina, hereby certify that C L- KrLl-4- CCU appeared personally before me this day and being duly
sworn acknowledge that the above f m was executed by him.
Witness my hand and notary seal, this 9 day of Dec r?Wtb r"y , 20Z 1
Seal __ _.. ._... -- (;zo_ -t s Y ► i Clr-�t ,
Rachel Martin Hay:27.
Notary
NOTARY C County
My Commission expires 7 d Qd5
Gaston County
North Carolina Print Farm
My C
ommisslon Expires May 025