NCC233126_FRO Submitted_20231019

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
CLAY-2023-001 (Cook's Construction, LLC and Holcomb Land Development, LLC
1. Project Name
*If this project involves American Rescue Plan Act (ARPA) funds. list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
Clay Hiawassee
2. Location of land-disturbing activity: County City or Township
Ashe Knob Road 35.04141 -83.74432
Highway/Street Latitude(decimal degrees) Longitude(decimaldegrees)_
7/29/2022
3. Approximate date land-disturbing activity will commence:
Residential
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
6.93
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
0.00
6. Amount of fee enclosed: $ . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed E No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Kevin Holcomb [e-mail]
Name E-mail Address
706-835-9398 706-835-9398
Phone: Office# Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Holcomb Land Development, LLC 706-835-9398 706-835-9398
Name Phone: Office# Mobile#
3053 Hooper Branch Road 3053 Hooper Branch Road
Current Mailing Address Current Street Address
Hiawassee, GA 30546 Hiawassee, GA 30546
City State Zip City State Zip
449 149
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Cook's Construction, LLC [e-mail]
Company Name E-mail Address
PO Box 111 212 Hillcrest Drive
Current Mailing Address Current Street Address
Hayesville, NC 28904 Hayesville, NC 28904
City State Zip City State Zip
828-361-8743 828-361-8743
Phone: Office# Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Kevin Holcomb [e-mail]
Name of Registered Agent E-mail Address
3053 Hooper Branch Road 3053 Hooper Branch Road
Current Mailing Address Current Street Address
Hiawassee, GA 30546 Hiawassee, GA 30546
City State Zip City State Zip
706-835-9398 706-835-9398
Phone: Office# Mobile#
Kevin Holcomb
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information sh uld there be any change in the information provided herein.
Norev CAL CS ccsfw. Are,,e47 orlprint name Title or Authority
a u DaP/23
I, (_O\\\\ O\ N\ 1-\.6\ C>116 , a Notary Public of the County of C\ ox k--e
State of North Carolina, hereby certify that S 0.c+1 (,a 6k_ appeared personally
before me this day and being duly sworn acknowledged at the above form was executed by him/her.
Witness my hand and notarial seal, this ay of pfiikil0Q,c , 20
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Cook's Construction, LLC 828-361-8743 828-361-8743
Name Phone: Office# Mobile#
PO Box 111 212 Hillcrest Drive
Current Mailing Address Current Street Address
Hayesville, NC 28904 Hayesville, NC 28904
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. _ Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Kevin Holcomb/Holcomb Land Development, LLC President
Type or print name Title or Authority
9-28-2023
Ce.Rv e._a.�
Signature Date
Kayla M Holcomb Cherokee
I, , a Notary Public of the County of
Kevin Holcomb/Holcomb Land Developemnt,LLC
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
28th September 23
Witness mar hand and notarial seal, this day of , 20
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