NCC221225_FRO Submitted_20220331

�� SOIL EROSION and SEDIMENTATION CONTROL
`' Lincoln County Natural Resources Department
RRCFS 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 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 NIA in the blank.)
Part A 1
1. Project Name ai'(h n
2. Location of land -disturbing activity: Latitude Long/
Parcel Identification Number (PIN) 1 bQ53 Watershed
Highway/Street Address '7 O F cWheft kef. J_ irnroln 6r__Z A
ve(
3. Approximate date land -disturbing activity will commence: Sfl P
4. Purpose of development (residential, commercial, industrial, institutional, etc.): `la('l�Yt tt �� rLiCtr�lL�
J 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14, )1 ac r-e
6. Amount of fee enclosed: $ 1 obo - bL ` . 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 /\
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name A&Aw Law+nr,� E-mail Address �,t)Ra1d-n('o0S-�w(fibrl (CmCtt1. (cm
Telephone
Cell # `16'1' ` 0 -'16 11 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Go'n and SWviift iylbnwy_ -low- 7Ib-3SP)o
Name Telephone
P11("90
Current Mailing Address Current Street Address
FIy_t L 61�tl
City State zip City
{10q- ;2 i +0811
_Pw Number
State
Zip
10. Deed Book No 52 -1 Page No. (0 -22 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
Current Street Address
Slate Zip City
Fax Number
State Zip

SOIL EROSION and SEDIMENTATION CONTROL
a Lincoln County Natural Resources Department
R 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY I 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):
bifle Woyrrh(l'In 6vi&- wchw UC
Name
(06-19 EQsi H WI VV(L. 'j 150
Current Mailing Addre&t I�~
MCIltlefi . NL A650
City State zip
Telephone 1,70 - 619 - 461 1
E-mail Address
Current Street Address
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
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:
c_ PC i'tf )Cdcme-cpc, nef
Engineering Firm or other consultant E-mail Address
M twnl no I I t t N C 213120
Current Mailing Address City State Zip
1100 MAtenn 5 o4 --_
Individual coat t person (type or print) Telephone Fax Number

0 0
SOIL EROSION and SEDIMENTATION CONTROL
' Lincoln County Natural Resources Department
R , � 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors andlor Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person or Firm
of Person or Firm
Current Mailing Address Current Street Address
MaidenPic&—& 0
City �' State Zip City Stale Zip
AdUm Ut W .i nc,
Individual contact person pe or print) Individual contact person (type or print)
Telephone _r bb 1- P1q" /I(PI � Telephone
Fax Number
Fax Nu
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.
Adam Lawing
Type or print name
Signature
owner
Title or Authority
3/25/2022
Date
a Notary Public of the County of 1 n1 f JYL
State of North Carolina, hereby certify that d, 61ti )1111 1 d{ W 1(f4 � _ _ appeared personally before
me this day and being duly sworn acknowledged that the above fob executed by him.
11/1
Witness my hand and notarial seal, this day of 20
4
%� N
My commission expires
z, •' .� p,R Y
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