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HomeMy WebLinkAboutNCC230801_FRO Submitted (2)_20230327FINANCIAL 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 NIA in the blank.) Sign the original form in BLUE INK. Part A. 1. Project Name Twin Springs Estates 2. Location of land -disturbing activity: County Henderson Highway/Street Twin Springs Road Latitude 35.23'47" City Hendersonville Longitude "82.24'50" Property Identification Number(s) PIN's 9651886323 3. Approximate date land -disturbing activity will commence: Upon approval 4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential 13 Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.52 6. Amount of fee enclosed: $ 1,400.00 . 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 Enclosedyes 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Oleg Korchican E-mail Address olegP Hejvr i_1- c- , c o v­ Telephone [92,8) 230 —770 0 3. Landowner(s) of Record (attach accompanied page to list additional owners): Longlife Properties, L.L.C. r2,S Lt 2, o — it Li Name Telephone 1000 f1�eh� �� ps^�ut I f f oc)o �}✓ev,t'�n�yrV� , /? i 1-7 Current Mailing Address Current Street Address Arm NC `J70(A A�-de­, NL V70�1 City State Zip City State Zip 10. Deed Book No. 3682 Page No. 77 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. Na E-mall Addr s Current Mailing Address Current Street Address Asc t!_ /VL 2SJo1 A -k Al 970 City - State Zip^ City State Zip Telephone ��S �� Z�Q l fl S H 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 (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 WU AVa, Ti i*e_ Ur'i JL 1 Ato) A III woo 1P_,k, _, I1�0,)-- Current Mailing Address Current Street Address City State Zip City State Zip Telephone Ca,sy) 2`IO _ IIS1 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 attomey-i n -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. PC, CA(,Ck Ov-GL, 1-- Type of print name Signature Title or Authority 11 22 Dat �o\fCA •.A�7, , a Notary Public of the County of Krk Cc LtLc State of itf 04\A Co�ca1� N � , hereby certify that fit)a 4+\G �CQ Q i /� appeared personally before me this day and being duly sworn acknowledge that the above form was executed by him. , r Witness my hand and notarial seal, this A� day of N,OdJZ uk�t 20 22 ,%III Plot ;C9Gnissio;.• Cry u dr /ice •A&.. �• NOTARY �'•:� : _ My commission expires /L 2-7zq •• `/',��f r�ayy •• �i �� CO� `11:.% Oii��� • • • O, `�,,`,� f 171 11 k15