NCC240240_FRO Submitted_20240126

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
"'TURAI-` 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RCSOURCC.5
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
RICK GERMAN
Name of Person or Firm Name of Person or Firm
17301 STATESVILLE RD 17301 STATESVILLE RD
Current Mailing Address Current Street Address
CORNELIUS NC 28031 CORNELIUS NC 28031
City State Zip City State Zip
RICK GERMAN
Individual contact person (type or print) Individual contact person (type or print)
704-363-3449
Telephone Telephone
Fax Number Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
TROY DALLY CHIEF FINANCIAL OFFICER
Type or print name .� Title or Authority
Signatur \ Date
r(
L l�1 r o.��w. , a Notary Public of the County of \
State of North Carolina, hereby certify that appeared personally before
me this day and being duly sworn acknowledged that thbove form was executed by him.
Witness my hand and notarial seal,this day of ("CAo' r r , 20 23
19d A.etk -
Notary
Seal
My commission expires \ 2-\ 21;2-
fo

Print Form
At, SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
• NATURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
RCSOURCES•
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A
1. Project NameGRACE COVENANT CHURCH
2. Location of land-disturbing activity: Latitude35°27'23.90"N Longitude80°59'21.18"W
Parcel Identification Number(PIN)4602776018 Watershed Area
Highway/Street AddressHAGERS FERRY RD
3. Approximate date land-disturbing activity will commence:11/25/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.):COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):9.855 ac.
6. Amount of fee enclosed:$2,000 .The Standard Permitting application fee of$200.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:9 acres total$1,800).The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount. In addition,the Express Permitting supplement is$250.00 per acre up to eight
acres,after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example: 9 acres total$3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameRICK GERMAN E-mail [e-mail]
Telephone[phone] Cell# 704-363-3449 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
International Church of the Foursquare Gospel '-° -1 (4 /;; N/A
Name Telephone Fax Number
17301 STATESVILLE ROAD 17301 STATESVILLE ROAD
Current Mailing Address Current Street Address
CORNELIUS NC 28031 CORNELIUS NC 28031
City State Zip City State Zip
10. Deed Book No.2689 Page No.115 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

°Lh SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
• L1T(1R 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
'-.RC50U RC CS•�
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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 an attached sheet):
International Church of the Foursquare C Troy Daily
Name E-mail Address
17301 STATESVILLE RD 17301 STATESVILLE RD
Current Mailing Address Current Street Address
CORNELIUS NC 28031 CORNELIUS NC 28031
City State Zip City State Zip
Telephone[phone] Fax NumberN/A
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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an 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:
CLIFTON GLENN
Name of Registered Agent E-mail Address
1142 WESTOVER TERRACE 1142 WESTOVER TERRACE
Current Mailing Address Current Street Address
ASHEBORO NC 27205 ASHEBORO NC 27205
City State Zip City State Zip
Telephone 7V% 4> Fax Number A./.,27
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
YARBROUGH-WILLIAMS & HOULE, INC [e-mail]
Engineering Firm or other consultant E-mail Address
PO BOX 1198 PINEVILLE NC 28134
Current Mailing Address City State Zip
VINCENT G. KEENE, PE 704-556-1990 704-556-0505
Individual contact person(type or print) Telephone Fax Number