NCC230369_FRO Submitted_20230209

.' BUNCOMBE COUNTY
[phone] - [e-mail]
www.buncombecounty.orgiplanning
INSTRUCTIONS: All sections must be completed. Section E must be
completed in the presence or a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FOR AN
EROSION CONTROL PERMIT
CASE NUMBER:
ion
PIN (Numbers): 9720-76-5362 Project Name: 471 Oiivette
Latitude: 35.637091 Longitude:-82.611555 Amount of fee enclosed: $
Project Location - ILighway/Street: 471 Olivette Road
Proposed Use: ❑ Single Family Residence ❑ A?ulti-Family ❑ Vacation Rental at Commercial/Industrial/Other ❑ Oth er
Proposed Disturbed Area (Include offsite borrow and waste areas): 6_8 acre(s)
Section 26-228(b) ofthe 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 ofthe County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised ofthe requirements therein as
well as the penalties and resources available to the County in the event ofviolation ofthe Ordinance, including revocation ofthe Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
471 Olivette, LLC pp Josh Holmes Name of Business: Name of A licant;
Mailing Address: PO Box 17335, Asheville, NC 28816�
Street address:
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
C. Landowner(s) of Recoid-
Name of Landowner(s) of Record. 471 Olivette, LLC
Mailing Address: PO Box 17335, Asheville, NC 28816
Recorded in Deed Book No: 6182 Page: 761
Section 26-228(b) ofthe 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 correspondence regarding the aforementioned project.
Name of Agent:
Mailing Address:
E-mail address:
Telephone: _ Cell:___ 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 ofthe 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 ofthe Ordinance. T above information is true and correct to the best of my knowledge and belief and was
provided by me while under o th.
Name: Josh Holmes 0o member manager
Title:
Signat Date: /%W' _
a Notary Public for the County of O �e
State of ® 2"/,*� hereby certify that, QO l m es ersonall
� Y
appeared before me this day and under oath a knowledged that the above form was executed by him and is correct to the best of his
knowledge and belief
No mol uly__ of
Notary PUNIC N ry Ste it%nA Ad i e.
Buncombe 'oun
North Car lin
row COP?1!T?fs siC r �.Xfllre5 J l ommission Expires 0 0 2
OFFICE Review Fee: S P�rrnit No.: Check No: _
USE Date Paid: Received by _ Date Issued:
the (ounty of Buncombe does not discriminate on ,'he basis of disability in the admission or access to, or treatment or emplovment in,
its programs or activities. Requests for appropriate aiailiar�, 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 Counols TDD number is [phone].