NCC231051_FRO Submitted_20230414

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION ANI) SEDIMENTATION CONTROL
1*\-t
No person may any land-distill Nog activity on one or more acres as covered by the Ordinance before this form
and an acceptable cnision And sedimentation control plan have been completed and approved by the Catawba County
Utilities and Engineering Deilativitenl Orate Wm or PM', mid If qiimllon ic nal applicable,please N/A in the blank)
PART A
I. kb Name I c..SA Jel( lct
C.
2 PIN C1T t)11 NkldreS I S 2`q ri 31/441 111 9,/4-1 /e/ .541 ,1/S 71'&1 RC Zt3.4
Purpose of dorlopmcnt ttestilentint,commercial, industrial, institutional,etc.)J
4 Approximate Olt disturbance date 1.2///202.3
5 Total aattsge disturbed or uncovered(including off-site borrow and waste areas)I IS" ele,c_e 5
b. His an im-Kzion and sedimentation control been filed? 7 yes r", No VAttached
7.If yclu have an Erosion Control billing account,would you like this to be billed? n Yes V.No
kccount Number I
PEOPLE •
E. Pe.. s_ on to ntact should erosion and sediment control issues arise during land-disturbing activity
-'sinit'N'e I i E-mail address
4 Lir.,z 1:0.21 e.:—S lit e • eceit
Telephone ; Cell# I Fax# I
9. Landavinfa(s)of Record(attach accompanied page to list additional owners)
Name IVk LLcL
. Telephone /70 - 5t --23dIVFax# Ii
Cu'lMailing Address 1711 I • lAdd
City e_44i,A State I hia,14. 6 I
•
Current Street Address I r12."II I
City 1 611A,„ State 14.4- Zip [ 21.6 oet
10. Deed Book No. 03631 Page No. I on,/,
PART B
1. Person(a)or firm(s)who are financially responsible for the hind-disturbing activity(Provide a comprehensive list
of all responsible parties on attached sheet):
Name ! V k rn,t-4, i E-mail address I
etoteodti
fcprrent Mailing Address I 921
city .... ..................... .... ...... ... .. .. State
I 4644. I Zip L2810 a?

Cumin Street Address I 72 91 L.', .i. 1,-d k.d
tate S
City eR 1_ '� /Vv�-�i f,.�40 Zip I I2e2
Telephone 16 z c yr; 8% 7/ 7.5' Fax Ii
2. (a) If the financially responsible pasty Is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent
Name I F,-tttall address r „
Ctttrcnt t\iailitl8 :1ddre�s f - - ,.,Y, i
City I Stole I I Zip
Current Street Address r---"--
City I State I , Zip I
Telephone I Fax# I
_ ail If the financially responsible party is a Partnership or other person engaging in business under assumed name,
st-tsc'r s copy of the Certificate of Assumed Name. If the financially responsible party is a Corporation,give name
L.-Li s_;et si±e of the Registered Agent:
\am: I E-mail address I
C_*_-,. t Mailbag..Address
rr z I State I Zip I
C_—�-Sit Address I - - --- -
Cry I : State I I Zip I
Telephone I Fax# I
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.
1 PA S i At-9.— b..L MA�A c.�
Ty Title of Authority
- /- l,3-a0/3
e Date
I, %"A C. it t«e AL, -ti ,a Notary Public of the County of d -1-e w b 4 State of North
Carolina.hereby certify tiiat_J/,,9/e gdd ,F�a.'I- ,/L appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
Witness my hand and notary seal,this („3i$ti1,111ttltrp,0l' _TnM�A^-y ,2023.
Seal ? .. Notary Public
., ' Catawba Notary
= County - My Commission expires 0 7- 31 16 2.
2
My Comm. Exp.
2 ,.
07 31 2027 �Q\: _ - •
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