NCC221282_FRO Submitted_20220405

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(828) 2504830 - [e-mail] EROSION CONTROL PERMIT
www.buncombecounty.org/planning
INSTRUCTIONS: All sections must be completed. Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
A. txisting Property Information
PIN (Numbers): 8687-28-1927 & 8687-18-7886 Project Name: Georges Branch
Latitude: 35.55717 Longitude:-82.75816 Amount of fee enclosed: $ 2,625.00
Project Location - Highway/Street: 269 Georges Branch Road
Proposed Use: ❑ Single Family Residence ❑ Multi -Family ❑ Vacation Rental ❑ Commercial/Industrial/Other ❑ Other
Proposed Disturbed Area (Include offsite borrow and waste areas): 2.50 acre(s)
B. Contact Information — Financially Responsible Person
Section 26-228(b) of the 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 of the County of
Buncombe Soil Erosion and Sedimentation Control 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, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business. Freedom In Christ Inc. Name of Applicant: Art Bayluk
Mailing Address: 89 Pete Luther Road Candler NC 28715
Street address: 89 Pete Luther Road Candler NC 28715
E-mail address: artemCdQrpmcarolina.
Telephone: 82 242- 7 Cell: Fax:
C. Londo-wner(s) of Record
Name of Landowners) of Record: Freedom In Christ Inc.
Mailing Address: 89 Pete Luther Road Candler NC 28715
Recorded in Deed. Book No: 5844 Page: 0287
r•
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the 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 noncompliance 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:
E. Certification
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 of the site until ownership is completed for the
above referenced project. I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have 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. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: Art Ba luk Freedom In Christ Inc Title:
Signature: Date: 2 Z
I, A)Q 2 a f
a Notary Public for the County of
f-r
State ofJ ,hereby certify that ��� � ��'-� personally
appeared before=me this y an �� t,O&E acknowledged that the above form was executed y him and is correct to the best of his
knowledge and �AJ
0ef. ,o/ `
Witness my hand f�cl,sea�l! sl�Tday of Z Cu/12U a
Notary
My Commission ires
OFFICE Review Fee: $ 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 he made by contacting
Buncombe County Erosion Control, [phone]..Buncombe County'.s TDD number is [phone].