NCC231608_FRO Submitted_20230526

ELAN KEVIF,W/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 for
and an acceptable erosion and sedimentation control plan have been completed and approved by the Catawba Count,
Utilities and Engineering Department. (Please type or print, and if question is not applicable, please N/A in the blar
PART A
1. Job Name I AZ,"/G•�. G'/ -, "Aor
2. PIN or 911 Address 137 -is- 5 - 39.s4 38/G 37 /3G��,5, , s7v? rqoo
3. Purpose of development (residential, commercial, industrial, institutional,etc.)I
4. Approximate soil disturbance date .3///,2a z�
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas)
6. Has an erosion and sedimentation control been filed? Eyes I- No 1 Attached
7. If you have an Erosion Control billing account,would you like this to be billed? (- Yes E No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Co/ell /96e.r f,• 14-4/ E-mail address I Qfroi,6•r/,.✓Tipp,./c-es 407
Telephone Iezg-2G7- 5-6at4/ Cell# I q2a-3•,/- „«7 -- Fax # I gzV- 32s - O/441/
9. Landowner(s) of Record(attach// accompanied page to list additional owners)
Name 14, do r Seacior l7ova,y-;`•vcs Telephone I 828- 3//.?y qg- Fax # Iff2y, ,•tejr. -/`! 9
Current Mailing Address I S6/ 24.Y4 /9v e /1/E
City /24•c,E7/, State I //C Zip r /
Current Street Address ,5-
4',w e .
City I State Zip
10. Deed Book No. (z9 yfc- Page No. (� 5
PART B
l. 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 I A74,;,"moo' $, /gore ,Sv�3 E-mail address I .a-' 4 3 e /,
Current Mailing Address I .O/ ?l® r /9v€ /l/.E
City I //cc,-b ./ State �l/ c Zip .•i'/

City J State
Zip
Telephone i aez.ca-^ s /_ z9 7ir 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: Al
Name I E-mail address I
Current Mailing Address I
City State j Zip
Current Street Address I •
City I . State r 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: ^/iAt
Name f E-mail address 1
Current Mailing Address 1
City I State I Zip l
Current Street Address
•
City i State I Zip
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 changein the information provided herein.
C Shu�a,d ,9Ierofe 1Z/e.t"` P e p•c,/eor P&
Type 'Pr' Name Title of Autho ity
Z 4Q / ,Z6-Z 57
Si, ature Date
I, J G.b �--1, (/`I , a N`cary Public of the County of_ (q,4 to a, State of North
Carolina, hereby certify that ,, 144,4Z H166416111 Ig appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
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d . 20
Witness my hand• f�n�iaxy}LWd9�tis 9 day of -
O ' • ‹.s.
Seal _ : p . _
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Ge L 1 C My Commission expires / /e4 .2..9, ..2J,_
County, o