NCC233080_FRO Submitted_20231013

HEouNr FINANCIAL RESPONSIBILITY/OWNERSHIP FORM NENOERso_'"T'3
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 N/A in the blank.)
Sign the original form in
Part A.
1. Project Name Pace Construction
2. Location of land-disturbing activity: County Henderson City hendersonville
Highway/Street422 Crest Road Latitude 35.288600 Longitude-82.406522
Property Identification Number(s)PIN's 9587-37-4651
3. Approximate date land-disturbing activity will commence: upon approval
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
industrial/commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .24
6. Amount of fee enclosed: $500'00 . 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 Enclosed yes
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mark Pace E-mail Address [e-mail]
Telephone
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Mark and Virginia Pace 828-242-1420
Name Telephone
171 Terrace Mountain Drive 171 Terrace Mountain Drive
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No.1396 Page No.014 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.
Mark and Virginia Pace [e-mail]
Name E-mail Address
171 Terrace Mountain Drive 171 Terrace Mountain Drive
Current Mailing Address Current Street Address
hendersonville NC 28739
City State Zip City State Zip
Telephone [phone] Fax Number n.a.

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Mark Pace Virginia Pace property owners
Type or print name Title or Authority
L4qauLe)
-2'?- -Za 2-3Signatu >Nt �� � Date j (_
66) o' -lO&(J , a Notary Public of the County of
State of NOr�{�. ( 140!1ya�' , hereby certify that J1'fctr/ '1&tdg rce- FG-C e
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this OLI day of ``� , 20
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NOTARY M1 I My commission expires Vol/ 15 9O7
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