NCC231214_FRO Submitted_20230426

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,please N/A in the blank)
PART A
1. Job NameSouthwest Blvd, Newton NC 28658
2. PIN or 911 Address (363912965957,363912966808,363912966767,363912967934,363912976084
3. Purpose of development(residential, commercial,industrial, institutional,etc.)residential
4. Approximate soil disturbance date I 4/5/2023
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) I 1.5 acre
6. Has an erosion and sedimentation control been filed? E Yes rx No IT Attached
7. If you have an Erosion Control billing account, would you like this to he billed? F. Yes J No
Account Number I
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name NitaliyGladysh , E-mail address [e-mail]
Telephone I Cell# 1113-237-7840 Fax
9. Landowner(s) of Record(attach accompanied page to list additional owners)
Name IGladysh Capital, LLC Telephone [113-237-7840 Fax#
Current Mailing Address 07 S Academy St
City l_incolnton State C Zip r8092
Current Street Address
City j State I Zip I
10. Deed Book No. 13795 Page No. I1 973
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 I3ladysh Capital, LLC E-mail address [e-mail]
Current Mailing Address 07 S Academy St
City Fjncolnton State INC Zip �8092

Current Street Address I
City I State Zip I
Telephone f4132377840 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 r E-mail address I
Current Mailing Address I
City State Zip I
Current Street Address I
City I State Zip
Telephone I Fax# I
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 I E-mail address
Current Mailing Address I
City State I Zip
Current Street Address I
City State Zip I
Telephone I 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.
Vitaliy Gladysh Owner
Type or Print Name Title of Authority
Signature Date
I, l°'c M‘v 461 et 1C6f a Notary Public of the County of Zi n Co'li, State of North
Carolina,hereby certify that 1/r - \„( S 1 Ct $k 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 30'rk day of Pt ar C h ,20
093
Seal �; pt.„,. / ef f.i
QLAOIMIR ARMENDARIZ
NOTARY PUBLIC Notary �y,�
Lincoln County, North Carolina My Commission expires Qo'-0 f, oct/d
My Comission Expires 08.04.2026