NCC232246_FRO Submitted_20230801

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(828)[e-mail] EROSION CONTROL PERMIT
www.buncombecounty.org/planning
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
A. Existint;Properry Information
PIN(Numbers): 'ma's ""'''°s "'a °'s Project Name: MadnOr Waaver,II Spas n5n
Latitude: 35.7110 Longitude: -82.5775 _ Amount of fee enclosed:S 7,875
Project Location-Highway/Street 60 011ie Weaver Rd/55 Garrison Branch No,2 Rd
Proposed Use: e Single Fannly Residence e.flu/ri-Funnily ❑ Vacation Rental ❑Commercial/Industrial/Other ❑Other
Proposed Disturbed Arca(Include offsite borrow and waste areas): 15 acre(s)'
B. Contact Information Financially Responsible Person
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: Madison Weaverville Owner,LLC Name of Applicant:Joe Teague
Mailing Address: 6805 Carnegie Boulevard,Suite 120,Charlotte,NC 28211
Street address: 6805 Carnegie Boulevard,Suite 120,Charlotte,NC 28211
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
C. Landowner(s)of Record
Name of Landowner(s)of Record: Madison Weaverviue Owner,LLC
Mailing Address: 6805 Carnegie Boulevard,suite 120,Charlotte,NC 28211
Recorded in Deed Book No: 6256/6243 Page; 404-413/1123-1125
D. Contact Information North Carolina Agent(If Applicable)
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:
lephonv: Cell: Fax:
S i e natum: Date:
E. Certification
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 under oath.
Name: Joe Teague/ 0/ Title: ?v i
Signatture: ` Date: 07 I2-3
1.^ '& ,�`a Notary Public for the County of t . 1
0011,�lyrn�nrp
State�`il 'WWt 4 vutt fll ,hereby certify that 5bf, lY �G6U� personally
ap arcf�bc re•mc4kls dtfy,af under oath acknowledged that the above form was cxecu by him and is correct to the best of his
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;Osfitncfi r acndand'seal.this i�t day of Celo I/�I ( ( � .20 2-J
g ® m — = Notary h 1\ V
-• P u B`�Cl •f� My Commission Expires
0FA0/1i •RevieW 1pe;S i�� Permit No.: Check No:
USE igr`r�i kaiid. sx', Received by:_ Date Issued:
The County o%}3utii'biiibt•does not discriminate on the basis of disability in the admission or access to,or treatment or employment in,
its programs or activities.Requests for appropriate auxiliary aids and services, when necessary to oiler a person With a disability an
equal opportunity to participate in or enjoy the benefits of County services, programs, or activities, may be made by contacting
Buncombe County Erosion Control.[phone]. Buncombe County'•TDD number is(828)250-4001.