NCC221196_FRO Submitted_20220329

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 NIA in the blank.)
Part A.
1. Project Name Dr. Wesley Grant Sr. Center Expansion
2. Location of land -disturbing activity: County Buncanabe City or Township Asheville
Highway/Street Livingston Street Latitude 35.57777 Longitude-82.56264
3. Approximate date land -disturbing activity will commence: Summer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 4.00 AC
6. Amount of fee enclosed: $ 260.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No ✓ Enclosed Vo
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dustin Clemens E-mail Address [e-mail]
Telephone [phone] Cell # 828-575-3851 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Asheville Parks and Recreation 828-259-5815 n/a
Name Telephone Fax Number
P.O. Box 7148 70 Court Plaza, 4th Floor
Current Mailing Address Current Street Address
Asheville NC 28802-7148 Asheville NC 28801
City State Zip City State Zip
10. Deed Book No. 1648 Page No. 214 Provide a copy of the most current deed.
Part B.
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.
Asheville Parks and Recreation [e-mail]
Name E-mail Address
P.O. Box 7148 70 Court Plaza, 4th Floor
Current Mailing Address Current Street Address
Asheville NC 28802-7148 Asheville NC 29801
City State Zip City State Zip
Telephone [phone] 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:
n/a
Name
n/a
Current Mailing Address
City State
Telephone
n/a
E-mail Address
n/a
Current Street Address
Zip City
Fax Number
State Zip
(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:
Jade Dundas
Name of Registered Agent
70 Court Plaza
Current Mailing Address
Asheville NC 28802-7148
City State Zip
Telephone S28-259-5621
[e-mail]
E-mail Address
70 Court Plaza
Current Street Address
Asheville NC 28802-7148
City State Zip
Fax Number n/a
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.
Jade Dundas
Director, Capital Projects
Type or print name Title or Authority
ignature Date
I, 1.4-0e- Gm �� , a Notary Public of the County of-bU.ECQ&%V'P
State of North Carolina, hereby certify that 5r�E 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 Z"A d
,-
Michelie F. SmIth
NOTARY PUB11c
Mecklenburg County
Sealr c>rth Caroiina
MY emission Expires Feb JarY 18, 2022
My commission expires 2 - ( i1.2 I