NCC232902_FRO Submitted_20230929

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 (Retail Store-Claremont
2. PIN or 911 Address 37621 3043750/0 Centennial Blvd,Claremont,NC 28610
3. Purpose of development(residential, commercial, industrial, institutional,etc.)'Commercial Retail Store
4. Approximate soil disturbance date I08/01/2023
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 12.32
6. Has an erosion and sedimentation control been filed? fll Yes ri No r Attached
7. If you have an Erosion Control billing account,would you like this to be billed? r"; Yes r No
Account Number I j
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name from James j E-mail address 1tssoas@tcooriem
Telephone I336855 Cell# I Fax# I
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name(Catawba Properties LLC Telephone I336-855-5555 Fax#
Current Mailing Address JP.0.Box 700
City [Claremont State INC Zip 128610
Current Street Address 13242 W Main Street
City 'Claremont State NC Zip 128610
10. Deed Book No. 12953 Page No. 10358
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 Claremont DG,LLC E-mail address [e-mail]
Current Mailing Address 600 Green Valley Road
City 'Greensboro State INC Zip 127404

Current Street Address 1600 Green Valley Road
City
(Greensboro State INC Zip 127404
Telephone [phone] , 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 I I E-mail address I
Current Mailing Address
City I State I Zip
Current Street Address I
City I State I I 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 (Jason B.Sparrow ! E-mail address [e-mail]
Current Mailing Address IP.O.Box 2888
City (Greensboro State INC Zip 127402
Current Street Address 1400 Bellemeade Street,Suite 800
City
(Greensboro I State INC Gip 127401
Telephone I3362715239 Fax# r
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.
Ion" C. -lines kCi/aaef
Ty ame - Title of Authority
v
Signature Date
I, thOYI,AL J , L ,a Notary Public of the County of C1 UAL & State of North
Carolina,hereby certify that — (rrn C_, J a,'VVte-s appeared personally before me this day and being duly
sworn ack osibigw,t, at the above form was executed by him.
Wit: sPyo Mi!4. p f'seal,this ZS day of ,20 L3
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PROPERTY OWNER CONSENT AFFIDAVIT
July 26, 2023
Catawba County
Utilities &Engineering Department
25 Government Drive
Newton,NC 28658
REFERENCE: Land-disturbing Activity Application
Parcel No: 376213043750
Address: 0 Centennial Blvd
Claremont,NC 28610
Catawba County
To Whom it May Concern:
We, CATAWBA PROEPRTIES, LLC,, swear that we are the property owner(s) of the above-
referenced subject parcel no. 376213043750 as shown in the records of CATAWBA COUNTY,
NORTH CAROLINA. We, as the owners, authorize CLAREMONT DG, LLC to act as the
applicant for all matters related to land disturbing activity on the subject parcel. This includes,but
is not limited to, submitting a draft erosion and sedimentation control plan and conducting the
anticipated land disturbing activity.
OWNER:
CATAWBA PROPERTIES,LLC
By:
Name: C 6)A IJ f - (:v n v( -
STATE OF IV C
COUNTY OF (� `- )
This instrument was q, pwledged before me on A(�J 2023.
`yOSARY r C '
0) PAY
RES•
cowl SICK"XPI
at r 3- Notary Public, State of tK
Printed Name: \
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��q �a My Commission Expires: �al;�11
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