NCC215482_FRO Submitted_20211005

FINANCIAL RESPONSIBILITY AND OWNERSHIP FORM
HAYWOOD COUNTY CODE OF ORDINANCES, CHAPTER 154 EROSION AND SEDIMENT CONTROL; and,
CHAPTER 158, SLOPE ORDINANCE
i�p�D CMG
xQ liC. y
�
No person may initiate a Laos
land -disturbing activity on one-half or more acres as covered by Chapter 154 before this form and an acceptable erosion
and sedimentation control plan have been completed and approved by the Haywood County Erosion Control Program. (Please type or print, and if
question is not applicable, place N/A in the blank.). This form also addresses artificial (i.e. cut or fill) scope construction and repair as covered by
Chapter 158. No Certificate of Occupancy will be issued and no final subdivision plat approved until the Erosion Control Office has received a
completed affidavit from the person financially responsible that the project site is in compliance with the Haywood County Slope Ordinance.
ECTION A.
1. Project Name: Ha ood EMC HQ Solar Project
2. Property Identification Number or Deed Book/Page:8608-35-4674
3. Address of land -disturbing activity: 376 Grindstone Rd. Waynesville, NC 28785
4. Starting date for land -disturbing activity: September 15th 2021
5. Purpose of this activity: []Residential requiring a Certificate of Occupancy, []Minor Subdivision, []Major Subdivision,
❑Commercial or Industrial requiring a Certificate of Occupancy, []XOther: Solar PV System for utility
6. Total acreage disturbed or uncovered (including off -site borrow or waste areas): 4
7. Fee enclosed: $ 1 400
Bond amount: $ N/A , Type of Security:
8. Has an erosion and sedimentation control plan been filed? Yes
9. 1 will notify Haywood County Erosion Control within 1_ p _days of when grading equipment is moved off the site.
10. Person to contact should sediment control or slope construction issues arise during land -disturbing activity:
Name: Phelps Clarke Telephone Numbers:828-713-8003
11. Landowner of Record (List all owners):
Name(s):
Mailing Address:
Telephone
Fax Number:
E-mail: rex.laroweCaD-haywoodemc com
12. Person or firm financially responsible for this land -disturbing activity and compliance with the Slope Ordinance:
Name: Pisgah Fntmmv _ iz ­ o __
Mailing Address:53 Asheland Ave. Suite 103 Asheville NC 28801
Telephone Numbers-99P-70F2_n-70n
Fax Number:
E-mail:evan.becka is lahenegy.com
13. My land -disturbing operator/contractor information is:
Name: Pisaah Fnarnv _
Mailing Address:
Telephone Numbers:
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 2 of 3
Initials of Financially Responsible Person
_<Da
14. My Building Contractor information is:
Name: N/A —
Mailing Address:
Telephone Numbers:
15. If the Financially Responsible Person is not a resident of North Carolina, give name and street address of a North
Carolina Agent:
Mailing Address
Street Address:
Telephone Numl
Fax Number:
E-mail:
16. If the Financially Responsible Person 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 Person is a corporation, give name
and street address of the Registered Agent.
Mailing Address:
Street Address:
Telephone Numbers:
Fax Number: , E-mail:
EC�TION B. ARTIFICIAL SLOPE REQUIREMENTS FOR ALL PROJECTS:
1- WYes, ❑No 4 1 understand that my project must comply with Chapter 158: Slope Ordinance
Ordinances before a Certificate of Occupancy can be issued. of the Haywood County Code of
2- tires, ONO 41 understand that all fill slopes must be compacted in accordance
compaction. (You may request a copy of the Standard Operating Procedures nor vi Op them g Procedure for
on the Erosion
Control's webpage)ew
3- ❑Yes, C�Pllo 4Does this project have any cut slopes steeper than 1:1 (horizontal: vertical) or fill slopes steeper than 1.5:1 (h:v)
and greater than fifteen feet (15') in vertical height? (Slope Plan is required, contact Erosion Control Office)
4- Res, ❑No 4Do all proposed artificial slopes meet the setback requirements in accordance with the Standard Operating
Procedures? **(The toe of a constructed fill slope and the top of a constructed cut slope cannot be within five feet
(5') of a property line.
5- ❑Yes, 140 -Will any artificial slope be taller than 40 feet (vertical) and stee e
4 required, contact the Erosion Control Office) P r than 1:1 (cut) or 1.5:1 (fill)? (Variance is
6-�tYes, pNo 41 will provide stabiliz
ed ditches or other methods to prevent uncontrolled stormwater runoff from going over
Artificially constructed or repaired slopes.
7- ❑Yes, L�fNo �Wili an offsite borrow sou
rce be used for fill slope construction or repair? If yes, provide the locations) of the
source (PIN, DB/PG, or address)
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 3 of 3
Initials of Financially Responsible Person
_C
ECTION C� ARTIFICIAL SLOPE REQUIREMENTS FOR MINOR AND MAJOR SUBDIVISIONS ONLY:
1- ❑Yes, QNo 4 My development activity is a MINOR SUBDIVISIO
plats will not be a N or a MAJOR SUBDIVISION. I understand that subdivision
pproved or recorded until all subdivision roads are completed and field verified for compliance
with the Slope Ordinance.
2- eYes, EDNo 4 1 understand that I must provide the Erosion
§158.10(A) of the Slope Ordinance on all
proposed ifillll soils forming ffice with nartificial slopesdard Proctor test data in accordance with
3- Gi(yes, ❑No 41 understand I must provide the Erosion Control Office
he final enineering ceificaons that are
provided to the State regarding the construction and t sting of'public es of tWATER and SEWER lines anytime said
utility lines are located in a fill slope. I further understand that the person financially responsible for the slope work
shall provide copies of the final engineering certifications within 30 calendar days of completion of the work.
THE FOLLOWING NOTARIZED STATEMENT MUST BE COMPLETED FOR ANY AND ALL SECTIONS OF THIS DOCUMENT.
(This form must be signed by the Financially Responsible Person, if an individual, or by his or her attorney -in -fact. If the Financially
Responsible Person is not an individual, this form must be signed by an officer, director, partner or registered agent with the
authority to execute instruments for the Financially Responsible Person.)
I agree to conduct all land -disturbing activity on the subject property in accordance with the information provided herein
and the Haywood County Code of Ordinances. I understand and acknowledge that Haywood County assumes no liability
for the design or adequacy of this plan or the work resultant from the approval of this plan, and I now and hereafter hold
harmless and indemnify Haywood County for all grading activities for which I am responsible. I have received, if
requested, a copy of the applicable Haywood County ordinances. I agree to provide corrected information should there be
any change in the information provided herein. All information I have provided in this form of Financial Responsibility and
Ownership is true and correct to the best of my knowledge. I understand that failure to comply with the Erosion and
Sediment Control Ordinance or the Slope Ordinance may result in the assessment of civil penalties.
r
Person Financially Responsible:
JF-MIL Name)
Land Owner:
(Signature)
r
(Print
a Notary Public of the County of
In the State of k ;11(iL r1%GkX
do hereby certify that 1
day and acknowledged the due execution of the foregoing instrument
personally appeared before me this
Witness my hand and Official Seal this _A_day of tits^
qq 20�.
r4 5p` G ���`� NotaNOTTry: ,
PPUE Y My commission expires: n a _
PUIBL1C U.
Rev_ 8-24-12 �200
00-