HomeMy WebLinkAboutNCC230529_FRO Submitted_20230227FINANCIAL 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 the
Land Quality Section, N.C. Department of Environment and Natural Resources. (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.)
Part A.
1. Project Name Jasmine
2. Location of land -disturbing activity: County Palk City or Township Columbus
Highway/Street Fox Mountain Road Latitude 35.255679 Longitude-82.183092
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.1 ac
6. Amount of fee enclosed: $ 520.00 . The application fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: a 3-acre application fee is $195).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James L. Yamin E-mail Address iim(aD-workforcehomestead.com
Telephone 828-351-9151 Cell # N/A Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jasmine Homestead LLC
Name
1534 Twisted Oak Drive
Current Mailing Address
Chapel Hill NC 27516
City State Zip
828-351-9151
Telephone Fax Number
Current Street Address
City
State
10. Deed Book No. 455 Page No. 836. Provide a copy of the most current deed.
Part B.
53
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Jasmine Homestead. LLC jim(a�workforcehomestead.com
Name E-mail Address
1534 Twisted Oak Drive
Current Mailing Address
Chapel Hill NC 27516
City State Zip
Current Street Address
City
State
0
Telephone 828-351-9151 Fax Number.
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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:
Deborah McKenney dlmO-blancolaw.com
Name of Registered Agent E-mail Address
PO Drawer 25008 404 N Marshall Street
Current Mailing Address Current Street Address
Winston-Salem NC 27114 Winston-Salem NC 27101
City State Zip City State Zip
Telephone 336-293-9000 Fax Number.
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.
James L. Yamin Authorized Representative
Type or print name Title or Authori y
Signature Date
I, 1` OLrCdnV - !Sn jQ.q , a Notary Public of the County of C'Kc �p►..-
State of North Carolina, hereby certify that Acume.3 L . 'I4yy%-,rA appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witne`t �r otarial seal, this day of , 20 2L-
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Notary �ev�
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