NCC240187_FRO Submitted_20240122

/JAG 148E CO`~�` BUNCOMBE COUNTY OFFICE USE ONLY
PLANNING & DEVELOPMENT SUB20
®1 (828) 2504830 - [e-mail]
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BUNCOMBE COUNTY
LAND DEVELOPMENT AND SUBDIVSION ORDINANCE
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
INSTRUCTIONS: All sections must be completed. Please type or print information. Section 5 must be
completed in the presence of a Notary Public.
1) Project Name: 1 l'hk- 11
Project Location: Highway/ Street: 91 TUr/+(c �a
Property Identification No. (PIN): 7 7 3 L(9 ' - 1 Z 1
Date: 01 —' I l _ Z OZ 9
2) Section 70-66(d) and (e) of the Buncombe County Land Development and Subdivision Ordinance: "Prior
to approval of a final plat with proposed public or private roads or prior to a release of a guarantee of
improvements for said subdivision, the developer shall submit a notarized statement of financial
responsibility for road maintenance which shall remain valid until the roads are dedicated to the North
Carolina Department of Transportation or an appropriate organization such as a homeowner's
association." This statement shall be signed by the person financially responsible for the subdivision
road(s) or his attorney in fact. The undersigned states that he/she is the person financially responsible for
the subdivision road(s) described in this application and acknowledges receipt of a copy of the Buncombe
County Land Development and Subdivision 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.
Name of Business: A 1-1-Q.mh(v'c- Cor15k1'U 4-Ion L-L C.
Name of Applicant: 3-Cif fc 091 &r W ►A(-44 5
Mailing Address: 139 L i f\d ^ S jc- Acd.2.1. , t/(_ 2� ']o 14-
Street address: lag C n.k4- S4- Md-e.^ , N C 2g.7 0 ck
E-mail address: Q to N a A 'kMcnk- NV L -
Telephone No.:en) q 7`t— (fl9 Cell No:(Z ) U 7 at
Fax no:( )
Signature: ' tL —
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3 Landowner(s) of Record: \ 5O DC3. �� iE ( (yi •1/4f
Name: 6ek )ek (\1 t( IMV\ tr\
Mailing Address: 2 0 W ewe- 'll e 'I CJ c 1kvrVi/lc GZ 7 $ 7
Deed Book No. : S v 1 2Page: 0 11
Recorded in
4) The above information is true and correct to the best of my knowledge and belief and was provided by
me while under oath. (If the financially responsible person is an individual, this form must be signed by
the individual or his attorney-in-fact; if the financially responsible person is not an individual, this form
must be signed by an officer, director, partner, or registered agent with authority to execute instruments
for the financially responsible person.)
Name: eC W h t Date: k — 2 LA
Title: Ow nor
M I
Signature: �irr ( ✓
I JC)hit\ a NotaryPublic for the CountyofO COu1be_
� ,
State of N 0( o I i no._ hereby certify that je,4ce.yby cal 1/Jki i e
, personally appeared before me this day and under oath acknowledged that the above form was executed
by them and is correct to the best of Their knowledge and belief.
Witness my hand and seal, this _ day of JArt, c.tckr'Y , 20 2gNo Lary
lOHN RA
NOTARY PUBLIC My omm on Cissi x ires O /2 to Z
1 p
Buncombe County
North Carolina
My Commission Expires Sep. 26, 2028
The County of Buncombe 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 offer 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 Planning and
Development [phone]. Buncombe County's TDD number is [phone] .
Last revised 4/16/19
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