NCC223769_FRO Submitted_20221107

SOIL EROSION and SEDIMENTATION CONTROL
ly �,
Lincoln County Natural Resources Department
NATUFAL 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
I . Project Name Huber Technology New Office and Machine Facility
2. Location of land -disturbing activity: Latitude 35.4685228 Longitude-81.0079014
Parcel Identification Number (PIN) 4603-21-1754 Watershed Area NIA
Highway/Street Address Airlie Parkway at Rufus Road ! _�
3. Approximate date land -disturbing activity will commence
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.94
6. Amount of fee enclosed: $ 2,200.00 . 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 Jim Bates E-mail Address [e-mail]
Telephone [phone] Cell # 704-512-1442 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Huber Technology Inc. 704-949-1010 704-949-1020
Name } '��.I�e. �aR Telephone , 1 A ` 6le Fax Number
,k way
Current marring /Auuitraa Current StreetAddress
��L NC N10f. NC_
City State Zip City State Zip
10. Deed Book No. 2761 Page No. 880-883 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
NIA
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NATURAL - > 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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FINANCIAL RESPONSIBILITY 1 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):
Huber Technology Inc. [e-mail]
Name ic)(nw� RR, � E-mail Address � Q �•tlttie \ 09
1L
Current Mailing Address
�n Je2 NC
City State Zip
Telephone [phone]
Current Street Address
n�r2 NC -�L_oo 3
City State Zip
Fax Number 704-949-1020
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:
NIA
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:
Hendrikus Johan Van Ettekoven Halk, ` � � C���45a•yY��
Name of Registered Agent E-mail Address
io'f)c +?.i� cry 1 1u�A IUCL� _tf'
Current ailing Address _! Current Street Address
City State Zip City State Zip
Telephone [phone]
Fax Number 704-949-1020
(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:
Stewart, Inc. [e-mail]
Engineering Firm or other consultant
101 N. Tryon Street, Suite 1400
Current Mailing Address
Riyad Baroudi, PE
Individual contact person (type or print)
E-mail Address
Charlotte NC 28202
City State Zip
704-909-3543
Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
4nruRnC. 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RESOCIRCES�
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Edifice, Inc.
Name of Person or Firm Name of Person or Firm
4111 South Blvd. 4111 South Blvd.
Current Mailing Address Current Street Address
Charlotte NC 28209 Charlotte NC 28209
City State Zip City State Zip
Jim Bates
Individual contact person (type or print) Individual contact person (type or print)
Telephone
704-332-0900
Fax Number 704-332-0901
Telephone
704-512-1442 (c)
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
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.
�baqA�c" Qorx PUe6jq , ' &4
Type or print name Title or Authority
Signature Date &02:2-
I, f/ 1 ���� a Notary Public of the Co��u�lntt,yj� of LI
State of North Carolina, hereby certify that kn'tf 1JJ 3C 11 }j A f�LteJW4ppeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this )tl day of L,5L20Q,1
Notary
Seal �j
My commission expiresAA'Q-0Si � J
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