NCC216336_FRO Submitted_20211118

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BUNCOMBE COUNTY
PLANNING & DEVELOPVIEN 1
(828) 2504830 - [e-mail]
www.buncombecountyorg/planning
INSTRUCTIONS: All sections must be completed. Section E must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FOR AN
EROSION CONTROL PERMIT
CASE NUMBER:
A. Existing Property Information
FIN (Numbers): 9623-85-5153 Project Name: LA VIGNE FARM
Latitude: 35.4419 Longitude:-82.5981 Amount of fee enclosed: S $2100
Project Location - Highway/Street: 99999 POWDER SPRINGS TRL
Proposed Use: n Single Family Residence ❑ Multi -Family ❑ Vacation Rental ❑ Commercial/IndustriaUOther ® Other
Proposed Disturbed Area 4. 0 () HORSE RIDING FARM
p (Include offsite borrow and waste areas): acre s
InformationB. Contact
Responsible
Section 26-228(b) ofthe Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership". This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact. The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy ofthe County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised ofthe requirements therein as
well as the penalties and resources available to the County in the event of violation ofthe Ordinance, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: 3 t !�c 'ems i_c i ie s+t-ir.Name of Applicant: Ma c\ j ii s Ca Jt P
Mailing Address: e-p rj r p ��- �� �� ZS7 I Z
Street address:
E-mailaddress:
Telephone:C31$, ZyZ'S'S7 Cell: Fax:
C. n.• i ofRecord
Name of Landowner(s) of Record: MARY LA VIGNE
Mailing Address: 245 S RICE ST - BREVARD, NC 28712
Recorded in Deed Book No: 6023 Page: 1287
ContactD. . .n — North Carolinar•
Section 26-228(b) ofthe Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Ifthe 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:
Telephone: Cell: Fax:
Signature: Date:
CertificationE.
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 ofthe site until ownership is completed for the
above referenced project. I acknowledge receipt of a copy ofthe County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised ofthe requirements therein as well as the penalties and resources available to the County in
the event of violation ofthe Ordinance. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. t
Name: "� ��p /LQ V v� Title: o W new
Signature: —`7 4Z, Date: L-- 10 acQ
I, a Notary Public for the County of nd
State of N U i" 11 C( Vol I hereby certify that M OUrk A i _a V j CAnP personally
appeared before me this day and under oath acknowledged that the above form as executed by hiln and is correct to the best of his
knowledge and belief
day of eL'1'1 E% , 20 1
LAU NOTARY
Y PUBLIC EY ,�� Y�'t chtL_C�rn.-Yr�
NOTARY PUBLIC Notary
ENDERSON COUNTY, NC My Commission Expires l — ZCl_.�
Permit No.: - -Check No:
USE Date Paid: Received by: Date Issued:
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 Erosion Control, [phone]. Buncombe County's TDD number is [phone].