NCC223659_FRO Submitted_20221026

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
Project Name Ecusta View Commons
2. Location of land -disturbing activity: County Transylvania City or Township Brevard
Highway/Street Highway 64 Latitude(decimal degrees) 35.267837 Longitude(decimal degrees) 82.708869
3. Approximate date land -disturbing activity will commence: 7/1/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.45 ac
6. Amount of fee enclosed $700 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Travis Fowler
Phone: Office # 828-884-7934
E-mail Address [e-mail]
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ecusta View Commons, LLC
Name
542 S. Caldwell Street
Current Mailing Address
828-884-7934
Phone: Office #
542 S. Caldwell Street
Current Street Address
►T[+7:�Il��d
Brevard NC 28712 Brevard NC 28712
City State Zip City State Zip
10. Deed Book No. 1044 Page No. 392 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible parlyfies).
Ecusta View Commons, LLC
Company Name
542 S. Caldwell Street
Current Mailing Address
Brevard NC 28712
City State Zip
[e-mail]
E-mail Address
542 S. Caldwell Street
Current Street Address
Brevard NC 28712
City State Zip
Phone: Office # 828-884-7934 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Travis Fowler
travis@f�stvictory.com
Name of Registered Agent
E-mail Address
542 S. Caldwell Street
542 S. Caldwell Street
Current Mailing Address
Current Street Address
Brevard NC 28712
Brevard NO 28712
City State Zip
City State Zip
Phone: Office # 828-884-7934
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
High Country Engineering, PC
Engineering firm or other consultant
Michael R. Goforth, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
828-230-4511
Phone: Office #
Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Travis Fowler
Type o rint name Title or Authority
Signature Date
I, bt i (Ia POLC a Notary Public of the County of TrarismW of
State of North Carolina, hereby certify that Tf'OL\1 LS A. FovJle-C appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this aq{n day of 5 eV }•2mhe7L , 20 421�j
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