NCC231978_FRO Submitted_20230629

,sr Diu
ccunrr a uNrr-
NENar �— FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 5 HENOESOD"
SEDIMENTATION POLLUTION CONTROL ACT
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 have been completed and
approved by Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Tuxedo Falls
2. Location of land-disturbing activity: County Henderson City Green River Township
Highway/Street Cabin Creek Road Latitude 35.216706 Longitude-82.472136
Property Identification Number(s)PlN's 9565-31-5911 , 9565-31-6679 & 9565-30-7834
3. Approximate date land-disturbing activity will commence:TBD
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Campground
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.48
1 100.00 ($1,400.00 previously paid)
6. Amount of fee enclosed: $ The application fee of$300.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac=$2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Lovoy, PE E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Daniel J. Park [phone]
Name Telephone
2101 Coniston PL 2101 Coniston PL
Current Mailing Address Current Street Address
Charlotte NC 20207 Charlotte NC 28207
City State Zip City State Zip
10. Deed Book No.003786 Page No.00591 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Tuxedo Falls, LLC Lark Elliott(Managing Member) [e-mail]
Name E-mail Address
2101 Coniston PL 2101 Coniston PL
Current Mailing Address Current Street Address
Charlotte NC 28207 Charlotte NC 28207
City State Zip City State Zip
Telephone[phone] Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
� •I l nvJuvt Mawe t
Type or rint name Title or Authority) u
Signature Date
I, 4(JJ 1-1-lc& S .MC ICe-lie i'! , a Notary Public of the County of l t/I.eC/C -ry
State of Ab r (tLio I i n hereby certify that La.--v kL P , E ll i o 4
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my ham,d iankiotarial seal, this (;?eday of /1/ �°'t' , 20
sive
o,%1 � ISSI
q •
�'n1 ,/iaer
QT'gR
tia ro . Notary
���e� °9..,,_?oz...0 ,� My commission expires