NCC224003_FRO Submitted_20221207

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A. Dodd Meadow Phase 3 & 6
1. Project Name
2. Location of land -disturbing activity: CountyHenderson City
Highway/StreetVolunteer Way Latitude 35D17'O9"N Longitude82D24'4O"W
Property Identification Number(s) PIN's 9587-25-4998,-26-2021,-2589,-5822
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
v
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.40
6. Amount of fee enclosed: $ 3,200 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Will Buie E-mail Address [e-mail]
Telephone [phone] x 302
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Henderson County Habitat for Humanity, Inc. [phone]
Name
1111 Keith Street
Telephone
1111 Keith Street
Current Mailing Address Current Street Address
Hendersonville NC 28792 Hendersonville NC 28792
City
State Zip City
State
Zip
10. Deed Book No. 1419 & 1613 Page No. 348 & 104,107,110 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Henderson County Habitat for Humanity, Inc. [e-mail]
Name
1111 Keith Street
Current Mailing Address
Hendersonville NC
City State
Telephone [phone]
E-mail Address
1111 Keith Street
Current Street Address
28792 Hendersonville NC 28792
Zip City
Fax Number
State
Zip

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(b) If the Financially 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 Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Linda Saturno
Type or print name
Signature
President/CEO, Henderson County Habitat for Humanity, Inc.
Title or Authority
Date
I �pp1 Tralf �. a Notary Public of the County of krli4erson
State of0&'4j►C_Mltr?e
appeared personally before me
form was executed by him.
hereby certify that
this day and being duly
WitnessQpRO' rfo Rgtarial seal, this
1 07-qR�.�`�
acknowledged that the above
My commission expires I t I3)