NCC230434_FRO Submitted_20230216

BUNCOMBE COUNTY
PLANNING & DEVELOPMENT
(828j 250 4 0 - [e-mail]
www.buncombecounty.orglplanning
INSTRUCTIONS: All sections must be completed. Section E must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM Fox AN
EROSION CONTROL PERMIT
CASE NUMBER:
A. Existing Property Inforniati(iii
PIN (Numbers): 9617-04-9117 & 9617-04-8235 project Name: Ash Road Minor Subdivision
Latitude: 35.5473 Longitude:-82.6621 Amount of fee enclosed: $ 792.75
Project Location - Highway/Street: 223 & 225 Asbury Road, Candler NC 2871 S
Proposed Use: X Single Fancily Residence ❑ Multi -Family ❑ Vacation Rental LiCommercial/Industrial/Other ❑Other
Proposed Disturbed Area (Inchide offsite borrow and waste areas): LS l acre(s)
B. Contact Infortnation—Financially Responsible Person
Section 26-228(b) of the 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 hiii attorney in fact. The undersigned states that helshe is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
welt as the penalties and resources available to the County in the event of violation of the Ordinance, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: Double Kay, LLC Name of Applicant: Mitch Miller
Mailing Address: 32 All Souls Crescent STE 202 Asheville NC 28803
Street address: 32 All Souls Crescent STE 202 Asheville NC 28803
E-mail address: mitch mountainoak ro erties.com
Telephone: [phone] Cell: Fax:
C. Landowner(s) of Record
Name of Landowner(s) of Record: Double Kay''L.L,C
Mailing Address: 32 All Souls Crescent STE 202 Asheville NC 28803
Recorded in Deed Book No: 6191 Page: 1 116
D.
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: If tire person financially responsible
is not a resident of North Carolina, a North Carolina agent must be designated in (lie 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 of the 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 of the Ordinance. Tire above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. �]�Je�
Name: � %r Title: sl �'�'` b/�
Signature: Date: �—
Notary Public for [lie Countyoft-D,l�,fil.M acwt
rSf,�,,Q,�-�
State of 1�1 m `Y % tLI_Y , hereby certify that MIR A 1 1 1`t/t personally
appeared before me this day and under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge acid belief.
�'�' `day 20
Witness my hand and seal, this of
Notary
My Commission Expires�N11
Krista T. Morgan '
ordi f i i a
Permit No.: Check No:
U
Received by: Date Issued:
rate on the basis ofdisability in the admission or access to, or tr•eahnent or employment in,
its programs a• activities, Requests for appropriate auxilimy aids and services, when necessary to offer a person with a disability an
equal opportunity to participate in or erloy the benefits of County services, programs, or activities, may be made by contacting
Buncombe County Erosion Convol, [phone]. Buncombe County's TDD number is [phone].