NCC216000_FRO Submitted_20211028

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on %2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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.
Project Name Hospice House of Foundation of WNC, Inc,
2. Location of land -disturbing activity: County _ Macon City or Township Franklin
Highway/Street 272 Maple Street Latitude _ . __ -___ _ __ _ . Longitude
3. Approximate date land -disturbing activity will commence: March 09, 2020
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 acre
6. Amount of fee enclosed: $E::_D 100.00._ The application fee of $100.00 per acre
is assessed without a ceiling amount (Example: a 1 acre -$100.00).
7. Has an erosion and sediment control plan been filed? Yes t_=L No.L_._�. Enclosed��
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Roger Bartlett E-mail Address [e-mail]
Telephone [phone] Cell # 828-399-1424 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
House House Foundation of WNC 828-524-6375
Name Telephone Fax Number
272 Maple Street - +— — — -272 Maple Street -
Current Mailing Address Current Street Address
Franklin NC 28734 Franklin NC 28734
City State Zip City State Zip
10, Deed Book No. J'35 Page No. 2160 Provide a copy of the most current deed.
Part B.
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.
Western Builders of Sylva, Inc Roger@WesternBuilderslnc,com
Name E-mail Address
PO Box 96 164 WBI Drive
Current Mailing Address Current Street Address
Sylva NC 28779 — -- Dillsboro NC 28725 -- -
City State Zip City State Zip

Telephone�Fax Number—.<. 828-586-4828
(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
City State Zip
Telephone .
Current Street Address
City State Zip
Fax Numbe
(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 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.
Roger Bartlett President
Type or print name Title or Authority
Sig
Date
03/06/2019
Rebecca Williams
1, a Notary Public of the Gc �' mHa y - bod
State of North Carolina, hereby certify that Roger BarTe t n t �, appeared
personally before me this day and being duly sworn acknowledgo"d"JI at e abo&:,form was
executed by him.
!lrrl�cJ'At,,,ff,11 ,
Witness my hand and notarial seal, this 6th day of 17 March 2019
Notar
Secil — —_
My commission expires-. 03/03/2-023