HomeMy WebLinkAboutNCC232839_FRO Submitted_20230926 AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
STREET ADDRESS and LATITUDE/LONGITUDE OF NEW CONSTRUCTION:
2289 Castle Peak Mtn, Connelly Springs, Lakeside Reserve Development, Burke County, NC 28612
Latitude: 35,781 Degrees North, Longitude: -81.453 Degrees West
Property Owner Name(s): Ann Gleysteen Smith
Property Owners Mailing Address:Ann Smith,
The undersigned,registered property owners of the above noted property, do hereby authorize ARDA
Designs,LLC and their employees to be my legal agent/ representative(s)for the purposes of securing
approval of a Erosion and Sedimentation Control Plan by the Land Quality Section of the NC Department
of Environmental Quality and to act on our behalf and take all actions necessary for the processing,
issuance, implementation and acceptance of this permit for the purposes of construction of a single
family residential structure on the indicated property. My legal agent/legal agent designee may be the
primary contact and may make decisions for me regarding my property for permitting, Erosion Control
Plan implementation, lot disturbance/excavation/ clearing,construction and inspection services.
Legal Agent/Representative Name: Debra Palmer
Legal Agent Current Mailing Address: 2089 Starboard Ln, Connelly Springs, NC 28612
Work/Mobile Phone: 704-747-2401 Email: DebiLpalrner@grnail.com
Legal Agent/Representative Signature. "'" Date' f
The undersigned person hereby agrees that he/she has read this form and that the contents of the same
are true as submitted.
Property Owner: Ann Smith
Property Owner Signature: d —, 4 Date: 1%21)/.13
County GIS#: REID 65614
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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 the
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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.)
Part A.
1. Project Name Jumping Run Cluster Subdivision— Lot 133
2. Location of land-disturbing activity: County Burke City or Township: Connelly Springs
Highway/Street2289 Castle Peak Mtn Latitude_35.781 Longitude_-81.453
3. Approximate date land-disturbing activity will commence: 31July2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_1/4 Acre
6. Amount of fee enclosed: $ 100.00 . The application fee of $100.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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: Debra Palmer E-mail Address: DebiLPalmer@gmail.com
Telephone: 704-747-2401 Cell #: 704-747-2401 Fax#: N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ann Gleysteen Smith 814-442-5602 N/A
Name Telephone Fax Number
35 Open Range Dr Same As Current Mailing Address
Current Mailing Address Current Street Address
Barnardsville, NC 28709 Same as Current Mailing Address
City State Zip City State Zip
10. Deed Book No._002685 Page No._00107 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.
Ann Gleysteen Smith annkift@gmail.com
Name E-mail Address
35 Open Range Dr Same As Current Mailing Address
Current Mailing Address Current Street Address
Barnardsville, NC 28709_ Same As Current Mailing Address
City State Zip City State Zip
Telephone_814-442-5602 Fax Number N/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:
Name ail Address
Current Mailing Address Current Street Address
City ate 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City to Zip City State Zip
Telephone 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 be any change in the information provided herein.
Ann Gleysteen Smith Property Owner
Type or print name Title or Authority
z ---X `7 ---- r/d // do) 3
Signature Date
I, ljr;4-4-ar4,� D Paley' , a Notary Public of the County of kEhcJ ersav1
State of North Carolina, hereby certify that Arvin &le yS/-eeh sMA-h appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this p�. I day of , 20 3
D ahat
BRITTANY D. DALEY Notary
NO 1 iY PUBLIC
Henderson County My commission expires /4 .4$' 3(t ZO
North Carolina
My Commission Expires August 31,2025