NCC231226_FRO Submitted_20230427

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 Name I Culver's of Hickory
2. PIN or 911 Address 371108898554
3. Purpose of development (residential, commercial, industrial, institutional,etc.) commercial
4. Approximate soil disturbance date May, 2023
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 1.88
6. Has an erosion and sedimentation control been filed? r Yes r No r Attached
7. If you have an Erosion Control billing account,would you like this to be billed? r Yes ® No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Jason Butts E-mail address [e-mail]
Telephone Cell # 1-9 19-219-3437 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name McDonald Road Properties LLC Telephone Fax #
Current Mailing Address PO Box 639
City Hickory State NC Zip 28603
Current Street Address
City State Zip
10. Deed Book No. 2356 Page No. F584
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 JJT Property Hickory LLC E-mail address [e-mail]
Current Mailing Address 445 30th Ave. NW
City Hickory State NC Zip 1 28601

Current Street Address Same
City State Zip F
Telephone g 17-952-9367 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:
NameF- E-mail address
Current Mailing Address
City State Zip ��-
Current Street Address
State Zip City F­
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 parry 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_Ih-erein.
Jon Howe (�(�St c�A
Type or Prinf^Vame Tie p f Autb ority
gna re Date/ G �j
a Notary Public of the County of State of-lerth-
7@m"% ,hereby certify than? � � appeared personally before me this day and being duly
worn acknowledge that the above form was executed by him.
Witness my hand and notary seal,this day of /�/(;'�X ,20
Seal
Notary
Officialseal My Commission expires
Notai y Public-State of Illinois
My commission Expires Oct 16, 2023 Print FOrm