NCC221922_FRO Submitted_20220520

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 NIA in the blank)
PART A
1. Job Name Long Grove Subdivision
2. PIN or 911 Address 606 Eastway Ln, SW, Conover, NC 28613
3. Purpose of development (residential, commercial, industrial, institutional,etc.)Residential
4. Approximate soil disturbance date 4-30-22
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) I13.91-acres
6. Has an erosion and sedimentation control been filed? F_ Yes F No r Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes r No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Steve Graves E-mail address [e-mail]
Telephone [phone] Cell # 704-928-7383 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name JRN Development, LLC Telephone [phone] Fax #F_
Current Mailing Address 7224 Statesville Rd
City [Charlotte State NC Zip F28269
Current Street Address 7224 Statesville RD
City Charlotte State NC Zip 28269
10. Deed Book No. 3652 Page No. 0517
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 JRN Development, LLC E-mail address [e-mail]
Current Mailing Address 7224 Statesville Rd
City Charlotte State NC Zip 28269

Current Street Address 7224 Statesville Rd
City Charlotte State NC Zip [28269
Telephone [phone] Fax #
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
City State Zip
Current Street Address
City State Zip
Telephone 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 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 should there be any change in the information provided herein.
91-d
Type or Print Name Title of Auth r'
ALA�.cQ le-3 L _
Signature Date
I,��C^ W `G a Notary Public of the County of Y C;�o State of North
Carolina, Vereby certify that a appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
Witness my hand and noiary seal, this -day of Xfr&L, 2022
Seal PEYTON WOODY
NOTARY PUBLIC
Iredell County
North Carolina
My Commission Expires
Myommission expires �J .L �'')5—
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