NCC223391_FRO Submitted_20220929

JACKSONCOUNTYPE,RMITTINC & CODE ENI"ORCE,ME,NT
Land Disturbance. One Half (112) or more Acres/Slor►ntvater Installation
Tinratrial Responsibility/Ownership Ibrm
Sylva Of)?ce: S38.S'colls Creek Rvad, Srdle 205, Phone: [phone] /Tnr. 828-586-7563
Cashiers Office: 357FrankAllen Road, Phone: [phone]/Fax: [phone]
No person may .initiate a land -disturbing activity and,/or stotrawatet installation on more than one-half acre as coveted bV th
Act before this forth and an acceptable erosion and sedimentation control/stonnwater plan have been completed and
approved by the Jackson County Office of Pcnnitthig & Code Enforcement. lfwork is started without an approved permit
-your permit fee Nvill be doubled.
Please type or print, and if any question is not applicable or the a -mail and/or fax information unavailable,
place N/A in the blank.
Submit three (3) copies of the plan, a narrative, and the appropriate fee, please contact our office for all
accurate fee calculation before subinitdng paperwork. For fee cafctdatiot► call 828-746-6850 or e-mail
or
+ A sutety bond is tcquired for any disturbance of five (6) acres or more
Pat t A
1. Project Name: Dilisboro RV Rivet Park PIN 7631-34-9299 / 7631-43-0655
2. Location of laird -disturbing activity/stormwater installation; (City or Township) Dilleboto
Highway/Street Mockingbird Lane _ Latitude 35,363 Longitude-83,247
3. This project will require the review of the following; W]Erosion Control E]Storrawater
Is this project within a regulated district? ONo Yes — District: Sacksoft Coun
4. Approximate date work will begirt onsitc: ll/1/22
5. Purpose of development (tesidenttal, coinmercial, Industrial, etc.) Comrnetcial RV Patk
6. Totat acteage disturbed or uncovered (including off -site borrow and waste areas), '2.=
7. Amount of fee ; 650 FOR OFFICE USE., Received? (initial/date) 'Sv - 1 •2.�
8. Has an erosion & sedimentation control/stormwater plan been. filed? DNo ❑Yes [f Enclosed
9. Person to contact should issues arise during land--distutbing activity/stotlnwater installation;
Name Loan Stillwell _ E-snail Address oanstillwekl frontlet.com
Phone [phone] Cell 828.507.8958 1 Fax N/A
10. Landowncrs(s) of Record (Use blank page to list additional owners) Deed Bk/Pg 769/364 ,1206/8t1 (Provide a copy)
Name Richard Stillwell Phone [phone] Fax N/A
Current Mailing Address 117 Monroe Buchanan Road, Sylya. NC 28774 ,
Part B
Company(ics) or finn(s) who are financially responsible for the land-distutbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietotsbip, the nature of the
owner or manager may be listed as the financially responsible paety,
Richard Stillwell
loanstillwell a3fronnet.com
Natne
V mail Address
117 Monroe Buchanan .Road
117 Monroe Buchanan Road
Mailing Address
Street Address
S lva NC
28779
S lva NC
28779��
City State
Zip Code.
City State
Zip Code
828.507.1541
N/A
Phone
Fa her
RECEIVED $P 12022

1, (a) If the Financially Responsible Party Is not a resident of North Carolina, please give name and street
address of a North Carolina Agent.
Name E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone Fax Number
(b) if the Financial 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 Financial Responsible
Party Is a Corporation, give name and street address of the Registered Agent.
Name of Registered Agent E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone Fax Number
The above Information Is true and correct to the best of my knowledge and belief and was provided by me under
oath. (This form mast be signed by 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 authority to execute
Instruments for the Financially Responsible Person), I agree to provide corrected Information should there
be any changes in the Information provided herein.
Richard Stillwell Owner
Ty e or Prinl Nam Title or Authority
g h'3 /2 .z
Ignature Date
I, a Notary Public of the County of, "aLQC:!N_ -_
State of North Carolina, hereby certify appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Hlm/Her.
Witness my hand and notarial seal, this 1 day of .mar 20.
,r��l6.464*406.
tlllll���`01'•nT�►R Y Notary
• '" ` i = My Commission Expires, �_kfll A\