NCC220703_FRO Submitted_20220214

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the
Henderson County. Submit this form to: 240 Second Avenue East, Hendersonville, NC 28792. (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.
Project Name First Aid Collision
2. Location of land -disturbing activity: County Henderson City or Township Hendersonville
Highway/Street Signal Hill Road Latitude 35.338840 Longitude-82.448317
3. Approximate date land -disturbing activity will commence: January 1, 2022 _
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.67
6. Amount of fee enclosed: $ 800 . The application fee of $300.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 7.2-acre application fee is $300.00
x 8 = $2400.00 plus $200.00 plan review fee = $2600.00).
'. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Zac Hix
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
JJJK Properties, LLC 828-684-4484
Name Telephone
Fax Number
369 Rockwood Road 369 Rockwood Road
Current Mailing Address Current Street Address
Arden NC 28704 Arden NC 28704
City State Zip City State Zip
10. Deed Book No. 3775 Page No. 675 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.
JJJK Properties, LLC [e-mail]
Name E-mail Address
369 Rockwood Road
Current Mailing Address
Arden NC
369 Rockwood Road
Current Street Address
28704 Arden NC 28704
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and streetaddress of
the designated North Carolina Agent:
E-mail Address
Current Mailing Address
Telephone
(b) If the Financially Responsible Party is m Partnership or other person engaging in business under an
assumed name, attach acopy mfthe Certificate mfAssumed Name. Ifthe Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Name ofRegistered Agent
Current Mailing Address
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number.
State Zip
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 K an kidividual
or his attorne&-fact, or if not an individual, by an officer, director, partner, or registered agent With:
the authority to execute instruments fDr the Financially Responsible Perscm� I agree to provide
corrected information should there be any change in the information provided herein.
[ a Notary Public of the County of
State of North Candine, hereby certify, that appeared
personally before rnothis day and being duly enmacknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this day of u\
u^&
Notary Public
,,,"Buncombe County
North Carolina
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Notary
My commission expires IkV�L At'�_f