NCC221941_FRO Submitted_20220523

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Land Quality Section, N.C. Department of Environmental Quality. (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. Crumpler Retail Store
1. Project Name
2. Location of land -disturbing activity: Coun#yAshe City or Township Walnut HIII
Highway/Street NC HWY 16 N Latitude 36.4669 _Longitude -g 1.3975
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.30
6. Amount of fee enclosed: $1 O5O The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Robert M. Broadway E-mail [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Jerry & Brenda Powers
NA NA
Name
Telephone Fax Number
281 Cranberry Creek Rd
281 Cranberry Creek Rd
Current Mailing Address
Current Street Address
Laurel Springs NC 28644
Laurel Springs NC 28644
City State Zip
City{ State Zip
10. Deed Book No.
I ® Page No.
-1 9
Iq 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):
The Broadway Group of Alabama LLC
[e-mail]
Name
E-mail Address
216 Westside Square
216 Westside Square
Current Mailing Address
Current Street Address
Huntsville AL 35804
Huntsville AL 35804
City State Zip
City State Zip
Telephone [phone]
Fax Number [phone]

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:
Scott Raines [e-mail]
Name
1 Page Ave, Ste 240
Current Mailing Address
Asheville NC
E-mail Address
1 Page Ave, Ste 240
Current Street Address
28801 Asheville NC 28801
City State Zip City State Zip
Telephone [phone] 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:
Douglas Pearson [e-mail]
Name of Registered Agent E-mail Address
611 N Church Street, Ste 109 611 N Church Street, Ste 109
Current Mailing Address
Hendersonville NC
City State
Telephone[phone]
Current Street Address
28792 Hendersonville
Zip City
Fax Number
NC 28792
State Zip
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Civil Design Concepts, PA [e-mail]
Engineering Firm or other consultant E-mail Address
Jesse Gardner [phone]
Individual contact person (type or print) 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.
Type
Signature
President & CEO
Title or Authority
Date
!,
allotary of the County of Ohio
State North Carolina, hereby
11
V
jP�ublic
1y�ry
t U
-
of certify that
IU
appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness hand 1 r ' T7­
my and notarial seal, this lJr day
of 1 20
IINA
' '•%�,r,
+NOTA
No
Seal
R%' =
My commission expires
...At,
`tc