NCC241831_FRO Submitted_20240614

c of AS,,,,,,
iiiiihFinancial Responsibility' DEVELOPMENT SERVICES DEPARTMENT
U m 161 SOUTH CHARLOTTE STREET
Ownership Form ASHEVILLE•NORTH CAROLINA•
c 28801
a M-F 8:30 AM-5:00 PM
�)-., cAcz- Sedimentation Pollution Control Act
INSTRUCTIONS: All sections must be completed. If not applicable enter Record Number:
N/A.Certification must be completed in the presence of a Notary Public.
A. Property Information /�
PIN(s): (iC7'/',70 .7l 0 �a c;L-,Lr'L,G) Project Name: i a4 „,,✓► Ae5i�.r�4( '
Project Location/Address: `>O iOri k. A r. AA : i (1 , /PE- vv7 6
Proposed Distrubed area (Include off site disturbance, burrow and waste areas): /CI eel) Acres or 'q. Ft. circle)
Proposed Development type: ingle Family Residential ❑ Multi-Family ❑ Commercial ❑ Industrial/Institution
❑Other
B. Contact Information-Financially Responsible Party
7-12-2(c)of the City of Asheville Unified Development Ordinance:"Financial responsibility and ownership:A financial
responsibility and ownership statement shall be required as a part of all completed permit applications.This financial
responsibility and ownership statement shall be signed by the person financially responsible for the land disturbing
activity or his/her attorney in fact.The statement shall include the mailing and street addresses of the principal place of
business of(1)the person financially responsible, (2)the owner of the property,and (3)any registered agents. If the
applicant is not the owner of the property to be disturbed,the permit application must include the owner's affidavit
form."The undersigned state that he/she is the person financially responsible for land disturbing activity described in
the permit application listed above and acknowledge City of Asheville Stormwater,Soil Erosion and Sedimentation
Control Ordinance and that he/she has thereby been advised of the requirements therein as well as the penalties in the
event of violation of this Ordinance.in ((�� ff
Name of Business/Person: , r cam l a.:4 l�e,r s Name of Applicant: L�r - f 44C(-7.Acce
2. -> - City: Qc;rJ .\); 1€ State:�L Zip:Z.7 /
Mailing Address: ��. � (no l�v�e- ��•
Street Address: ` "'� Telephone:
Cell: C.� G
Email address: pcA/'-NA�c� 4.e J'.\:..t c1Ae.5.5 vvic,; I. 6c' �L� �j
C. Property Owner:
Name of Landowner(s)of Record: f�cj; 4- ,rc,c[,e_ �:or�c?.�'✓`4ca..4
Mailing Address: >x 6 bi\re-1 ---1-• City: ,)c.,.) 1), State:kG Zip: (5C
Recorded in Deed Book No: Cy'cZ-F Page: S (0
D. Contact Information-North Carolina Agent(if Applicable)
7-12-2(c)of the City of Asheville Unified Development Ordinance: "If the person financially responsible is not a resident
of North Carolina,a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with this section."
Name of Agent:
Mailing Address: City: State: Zip:
Email address: Cell: Telephone:
Signature: Date:
I 1

E. Certification
I,the undersigned,attest that I am the financially responsible party or authorized representative with signatory
authority for the financially responsible party, responsible party for the construction activities and maintenance of the
site until ownership is completed for the above reference project. The above information is true and correct to the best
of my knowledge.
Name: —),re c� f" c_ 4 e' Title: /'!`CS;kcA
Crst4—
Signature: _ -%-----�"
Date: At / 7 211
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