NCC242641_FRO Submitted_20240830

FINANCIAL 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 the
Avery County Planning Department 200 Montezuma Street Newland NC 28657 (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.)
Part A.
1. Project Name +.Lc :,Lct ck-.1 t)
2. Location of land-disturbing activity: County Ave4,, City or Township :tA;:,
Highway/Street `''. 'Ic h 'Rer<c`Latitude LAC Longitude -S1.13 i CciC
3. Approximate date land-disturbing activity will commence: lez.(Ct .3i ,(-46 241-
4. Purpose of development(residential, commercial, industrial, institutional, etc.): eGivtayveefh(a.( � c a 7it�tLc.�
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .3•64res
6. Amount of fee enclosed:$ . $175.00 Grading Permit, $125.00 for review fee
7. Has an erosion and sediment control plan been approved: Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 5 ,'jjt, Cills( w:- c4 i;JE-mail Address jnt�rf e nit"
Telephone ( .2 ) 4 ?. CeN# (57,2c) € i! .21011 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
PrmO,:1 (&)- 7 3.3 /4,01
Name T- • . = Fax Number
a iO 5e i(rC( Creec I. re 1 Creek. +w •
Current MAddress Current Street Address
tan& � 565-j I`e ue blot_
City Stale Zip City State Zip
10. Deed Book No. R L 491 Page No. 1,21.4-! sc" Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Ar,`e�mmers� De
mc:N --cf„ � n c.. ,r,+�r p r 68 4r I.L be e
Namejy ` //� / [�j E-mail Address (� p
%C!7 [ ! IILv[ io.rlbt�l� [ 3rro, [ / (. ?1 4•`A f-, ,. r✓Y�i it ("red Rd.
Current Mailing Address Current Street Address
C glos7 c' (. g65 .7
City State ZIP CitY ZP
Telephone 3 -41(Ai page 5

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 Fax Number
(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 Add Current Street Address
City • State Zip City State Zip
Telephone Fax Number
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.
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f ,nan FuCk'n -rile--
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y Title or Authority
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Signature Date
I, Lpi J, Lk, kt, - n,t , a Notary Public of the County of 'Av
State of North Carolina, hereby certify that '
_r'Q� �1- appeared
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personalty before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 16A day of )U i, , 20 ad
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