NCC222259_FRO Submitted_20220623

BUNCOMBE COUNTY
PLANNING & DEVELOPMENT
(828) 250�830 - [e-mail]
www.buncombecounty.org/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:
PIN (Numbers): 9634-45-8752 Project Name: Walnut Cove Retail Center
Latitude: Longitude: Amount of fee enclosed: $ 1207.50
Project Location - Highway/Street: 1870 Brevard Rd
Proposed Use: ❑ Single Family Residence ❑ Multi -Family ❑ Vacation Rental il:/Commercial/IndustriallOther ❑ Other
Proposed Disturbed Area (Include offsite borrow and waste areas): 23 acre(s)
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: Walnut Valley, LLC Name of Applicant: Kent Smith
Mailing Address: 630 Long Shoals Road Arden, NC, 28704 _
Street address: 630 Lona Shoals Road Arden NC 28704
E-mail address:
Telephone: Cell: Fax:
Name of Landowner(s) of Record: Walnut Valley, LLC _
Mailing Address: 630 Lonp Shoals Road Arden. NC, 29704
Recorded in Deed Book No: 5631 Page: 1437
D. Contact Information — North Carolina Agent (J1'AI)J?JivAbA)
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 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 corresponndee'nce regazdin the aforementioned project.
Name of Agent: e
Mailing Address: O Zo ►►1A C
E-mail address: u c O
Telephone: Cell: C7U Fax:
Signature: Date:
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: Kent E "r"r rr Title: Managing Partner
Z�Signature.` Date:
I, I CL^ a Notary Public for the County of
State hereby certify that _personally
ho
appea& is d"d u*eFu&h acknowledged that the above form was executed by him and is correct to the best of his
knowidge drid beliFfUV`9 er
Witnesflj lj�Xd ada d seal. th _ / (20
n,% 0tobet 0b^• ' J
-,MBE GD`,,,, NO:a4_�wineeas
�rrrur moil,P� My Commission Expires �o
OFFICE Rev:ewFee $ PemutNo.. 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].