NCC230137_FRO Submitted_20230118

PLAN REVIEW/FINANCIAL 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, place NIA in the blank)
PART A Cape Townhomes
I. Job Name
2. PIN or911 address 3704-1701-7154
3. Purpose of development (residential, commercial, industrial, institutional, etc.)
4. Approximate soil disturbance date Oct 1, 2022
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.58
6. Has an erosion and sedimentation control plan been filed? Yes No Attached X
7. If you have an Erosion Control billing account, would you like this to be billed? Yes_ No X
Account number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Hunt Broyhill E-mail address HuntPbroyhillasset.com
Telephone 828.610,5360 Cell 4 828.312.4069 Fax ##
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Broyhill Investments, Inc.
828.610.5360
Name
Telephone Fax Number
800 Hickory Blvd. SW
800 Hickory Blvd. SW
Current Mailing Address
Current Street Address
Lenoir NC 28645
Lenoir NC 28645
City State Zip
City State Zip
10. Deed Book No. 2851 Page No. 0671
PART 13
I . 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);
Broyhill Investments, Inc
[e-mail]
Nance
E-mail Address
800 Hickory Blvd SW
800 Hickory Blvd. SW
Current Mailing Address
Current Street Address
Lenoir NC 28645
Lenoir NC 28645
City State Zip
City State Zip
828.610,5360
Telephone
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
2. (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
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). 1 agree to provide corrected information should there be
any change in the information provided herein.
141,17 /4 4 �,4 'e /V
Type or print nag e Title or Authority
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ggna ure Date
I, g 1eb CCCCk y • Be0- -'—? , a Notary Public of the County of1��Clw'lj
State of North Carolina, hereby certify that . i�-�iJ�rl't' i�iJ� U�'1 ? _ appeared
personally before me tj}sg A and being duly sworn acknowledge that the above form was executed by him.
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Witness my 1`a>�and noi�� setts day of 200_
W Se I CA W - V
CD O � Notary
a ?N 1JZE5O�'` My commission expires