NCC233062_FRO Submitted_20231024

.LINTY COUNTY
HENDER50� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HENOERso_`
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 BLUE INK.
Part A.
1. Project Name Haywood Park Subdivision
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street Haywood Road Latitude Longitude
Property Identification Number(s) PIN's
3. Approximate date land-disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5.43
6. Amount of fee enclosed: $2000 . 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Luis Graef E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Haywood Park, LLC
Name Telephone
3872 NW 126 Ave 3872 NW 126 Ave
Current Mailing Address Current Street Address
Coral Springs FL 33065 Coral Springs FL 33065
City State Zip City State Zip
10. Deed Book No. 3904 Page No.526 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.
Haywood Park, LLC
Name E-mail Address
3872 NW 126th Ave 3872 NW 126th Ave
Current Mailing Address Current Street Address
Coral Springs FL 33065 Coral Springs FL 33065
City State Zip City State Zip
Telephone [phone] 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:
Registered Agents Inc
Name E-mail Address
4030 Wake Forest Road Suite 349 4030 Wake Forest Road Suite 349
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
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.
Luis Graef Manager
Type or print name ' Title or Authority
y 10\zo`2�—
Signature Date
I, AySliet4k, I V 0.i a , a Notary Public of the County of 1 rn WO-nut
State of ci 0 If 1,O&AA , hereby certify that WIT G/Y12.111C
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him. r�
Witness my hand and notarial seal, this a 0 day of v CIO�'tn , 20 �Z
Notary Public State of Florida
Agustina Alvarez V.(2) \' ‘
My Commission
tl�l����� E p.3/24/2026 I Notary
s 3I29 2o7
My commission expires