NCC232150_FRO Submitted_20230808

"BE`° BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
�a 4y<
OWNERSHIP FORM FOR A
1Stcf [phone]•[e-mail] STORMWATER PERMIT
www.buncombecounty.org/planning
INSTRUCTIONS: All sections must be completed. Section D must be CASE NUMBER:
completed in the presence of a Notary Public.
A. Existing Property Information
Project Name: 1220 Charlotte Hwy
PIN(Numbers): 9686-23-0378
Latitude: 35.524532 Longitude: -82.422223 Amount of fee enclosed: $735
Project Location -Highway/Street: 1220 Charlotte Highway, Fairview
Proposed Use: ❑Single Family Residence ❑Multi-Family ❑ Vacation Rental I Commercial/Industrial ❑ Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 1.4 acre(s)
B. Applicant Contact information
Name of Applicant: JM HOLDINGS OF WNC LLC State of Business Registration (if applicable): NC
Applicant's Point of Contact (for official correspondence): Marshall Matthews
Mailing Address: 722 OLD FORT RD, FAIRVIEW, NC, 28730
Street address:
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
C. Landowner(s) of Record
Name of Landowner(s)of Record: JM HOLDINGS OF WNC LLC
Mailing Address: 722 OLD FORT RD, FAIRVIEW, NC, 28730
Recorded in Deed Book No: 6279 Page: 16
Name of Landowner(s)of Record:
Mailing Address:
Recorded in Deed Book No: Page:
Note:If applicant is not landowner of record,provide executed Buncombe County Stormwater Agent Authorization Form
D. Certification
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 installation, operation, and maintenance of the stormwater controls until ownership
is conveyed for the above referenced project. I acknowledge receipt of a copy of the County of Buncombe Stormwater Management
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. The above information is true and correct to the best of my knowledge and belief and
was provided by me while under oath.
Financially cA Respoonnsib e Party: , pe.......„(-1,l t1,0 c e:: U)i\)C. k i-.0
. t /v1)a02"3Silmaturc: Date:
Name: ,.Jhli fik,A7777w, /J&y5oi I t Ata t,tc ct Title: O tiL)Ak'I S .G /so
I,`1 ��x sr-,2 •�+-� A _ r- a Notary Public for the County ofe:::;,‘,..)r---,C- c--(NA: >Qom,
State of Y 4h c YZ-b.AJ� . ,hereby certify that i ► r,.y,t C),\` 1 ..\,1\CI\ la 4'�=,.j iSGr�i�ona
ftF
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 and belief. 2
Witness my hand and seal, this v 1 day of -air— 1 , 20 G,\1 .
MAUREEN A FOSTER Notary -A(N\ ,1,2671. -
NOTARY PUBLIC My Commission Expires c Q ,�.C
Buncombe County !!
North Carolina
My Commission Expires February 2, 2024
OFFICE Review Fee:$ Permit No.: Check No:
USE Date Paid: Received by: Date Issued:
The County of Buncombe does not discriminate on the basis of disability in the admission or access to, or treatment or employment in.
its programs or activities. Requests for appropriate auxiliary aids and services, wizen 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 he made by contacting
Buncombe County Erosion Control. [phone]. Buncombe County:s TDD number is(828) 250-4001.