NCC223670_FRO Submitted_20221116

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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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 iounavailable, place N/A inthe b|onk.)
Project Name Osborne Road Subdivision
2. Location ofland-disturbing activity: County City orTownship
Highway/Street Latitude(deci= degrees) 35.24912 Longitude(decimal degrees) 82.70958
3. Approximate date land -disturbing activity will commence: 90/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed oruncovered (including off -site borrow and waste areas)
G. Amount offee enclosed The Express Permitting application fee isadual 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 iaufixed $2'0U0.00(Exemp|a:O.1O-aonaapplication fee io$2.Q00). Checks
should boaddressed ioNCDE{l.
l
Has an erosion and sediment control plan been filed? Yes OEnclosed [K No El
8.
Person hocontact should erosion and sediment control iseues'arise during land -disturbing activity:
Name TomBorha
E-mail Address
Phone: Offica#
Mobile #
A.
Landowner(s) of Record (attach
accompanied page to list additional owners):
Parashift Holdings, LLC
828-884'6007
Name
Phone: Offioe# PWnbi|o#
41TuraoDr#5
41TomnDr#5
Current Mailing Address
Current Street Address
Brevard NC
28712 Brevard NC 28712
City State
Zip City State Zip
10.
Deed Book No. 1028
Page No. 505 Provide a copy of the most current deed.

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 ismsole proprietorship or if thelandowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
ParashiftHoldings, UC
Company Name E-mail Address
41ToreoDr#5 41TomnDr#5
Current Mailing Address Current Street Address
28712
City State Zip City State Zip
Phone: Offima# 828-884-5007 yNnbi|e#
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 hoconduct the anticipated land disturbing activity.
2. (a)|fthe Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address ofthe Registered Agent:
Michael K.Pratt
Name ofRegistered Agent E-mail Address
35NGaston Street 35NGaston Street
Current Mailing Address Current Street Address
Brevard NC 28712 Bmvard NC 28712
City State Zip City State Zip
Phone: Office# 838-8844113 Mobile #
Name of Individual to Contact (if Registered Agent is company)
(b) If the Financially Responsible Party is not a resident of North Coro|ine, give name and atneo1 gddnmaa
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name ofRegistered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# K8obika#
Name ofIndividual tuContact (if Registered Agent iaacompany)
(u)|fthe Financially Responsible Party ioengaging inbusiness under anassumed 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 828-231-9380
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.
Tore Borhaug Member/Manager
Type or n e Title or Authority
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
I, : G°rz a Notary Public of the County of
State of North Carolina, hereby certify that o r' % appeared personally
before me this day and being duly sworn acknowledged that the abov form was executed by him/her.
Witness my hand and notor,;WiseaJ,r this day of Ateji" , 20 _
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Seal,�;,,.", �.= My commission expires 1,? �-

Continued from Items 9 & YO /n Part of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners
Landowner 2ofRecord:
Name Phone: Uffice# yNobi|e#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3ofRecord:
Name
Current Mailing Address
Landowner 4of Record:
Name
Phone Dffice#
Current Street Address
State Zip City
Page No.
Current Mailing Address
City State
Deed Book No.
Landowner 5ofRecord:
Name
Current Mailing Address
State Zip
Provide a copy of the most current deed.
Phone: Office# Mobile #
Current Street Address
Zip City State Zip
Page No. Provide ocopy ofthe most current deed.
Phone: Office# Mobile #
Current Street Address
city State Zip City State Zip

Continued from Item Yin Part Bofthe Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page aaneeded 8mlist all financially responsible parties.
Company 2Name E-mail Address
Current Mailing Address ' Current Street Address
City State Zip City State Zip
Phone: Offioe# Mobile #
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #
Company 4Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #
Company 5Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #