NCC224068_FRO Submitted_20221209

INSTRUCTIONS: All sections must be completed. Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
PIN (Numbers): 8697-01-0602 Project Name: Lincoln Ridge Minor Subdivision
Latitude: 35.5378153 Longitude:-82.7345713 Amount of fee enclosed: $ 4,725.00
Project Location - Highway/Street: 420 Old US 19 23 Highway
Proposed Use: re Single Family Residence ❑ Multi -Family ❑ Vacation Rental ❑ Commercial/Industrial/Other 1Z Other
Proposed Disturbed Area (Include offsite borrow and waste areas): 9.0 acre(s)
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership". This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact. The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as the penalties and resources available to the County in the event of violation of the Ordinance, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: Hi -Alta Investments, LLC
Name of Applicant: Kevin Griffin
Mailing Address: 420 Old US 19 23 Highway Candler NC 28715
Street address: 420 Old US 19 23 Highway, Candler, NC 28715
E-mail address: [e-mail]
Telephone: [phone]
Name of Landowner(s) of Record: Hi -Alta Investments, LLC
Mailing Address: 420 Old US 19 23 H
Recorded in Deed Book No: 6099
, Candler, NC 28715
Page: 1773
Fax:
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person financially responsible
is not a resident of North Carolina, a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the plan, the Act, this ordinance, or rules or orders adopted or issued pursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent: _
Mailing Address:
E-mail address:
Telephone:
Signature:
Cell:
Date:
Fax:
I, the undersigned, attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party, responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project. I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County in
the event of violation of the Ordinance. The above information is true and correct to the best of my knowledge and belief and was
provided by me while tinder oath. ,.
Name:
Signature: _ fJ
State of —.Z
appeared be
knowledge
Witness my
Title: /?%.,, 4ee
Date: /z- 7-2z
a Notary Public for the County of� ,
-, hereby certify that E Aher� /� of7)T7}personally
acknowledged that the above form was executed by him and is correct to the best of his
belief.
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OFFICE
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Review Fee: $ Permit No.:_
n-- n_.A. Raro ,T 1—
Check No:
Date Issued: