NCC216080_FRO Submitted_20211104

JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Land Disturbance: One Half (112) or more Acres/Stormwater Installation
Financial Responsibility/Ownership Form
Sylva Office: 538 Scotts Creek Road, Suite 205, Phone: [phone] Fax: [phone]
CfiFt Cashiers Offlee: 357 Frank Allen Road, Phone: [phone] Fax: [phone]
No person may initiate a land -disturbing activity and/or stormwater installation on more than one-half acre as covered by the
Act before this form and an acceptable erosion and sedimentation control/stormwater plan have been completed and
approved by the Jackson County Office of Permitting & Code Enforcement. If work is started without an approved permit
your permit fee will be doubled.
• Please type or print, and if any question is not applicable or the e-mail and/or fax information unavailable,
place N/A in the blank.
• Submit three (3) copies of the plan, a narrative, and the appropriate fee; please contact our office for an
accurate fee calculation before submitting paperwork. For fee calculation call 828-745-6850 or e-mail
tiff anvqualls a„j_acksonnc.oM or jamiebaun.ngarnern& acksonnc.org.
• A surety bond is required for any disturbance of five (5) acres or more
Part A
1. Project Name: Hapn's Place Parking Lot Expansion PIN 7564-57-9499
2. Location of land -disturbing activity/stormwater installation: (City or Township) Glenville
Highway/Street HWY 107 N Latitude 35.18304 Longitude-83.13198
3. This project will require the review of the following: QErosion Control F�Stormwater
Is this project within a regulated district? W]No Dyes — District:
4. Approximate date work will begin onsite:
5. Purpose of development (residential, commercial, industrial, etc.) Commercial _
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4.89
7. Amount of fee $ 1,650.00 FOR OFFICE USE: Received? (initial/date)
8. Has an erosion & sedimentation control/stormwater plan been filed? [:]No Dyes W]Enclosed
9. Person to contact should issues arise during land -disturbing activity/stormwater installation:
Name matt Edsel E-mail Address wedselkbrooksea.com
Phone [phone] Cell Fax
10. Landowners(s) of Record (Use blank page to list additional owners) Deed Bk/Pg 23/7 (Provide a copy)
Name 01 Happs Place Land LLC Phone [phone] Fax
Current Mailing Address rfarrior3 rni yahoo.eom
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.
Ol Happs Place Land LLC rfarrior3na_,vahoo.com
Name E-mail Address
5914 Hwy 107 5914 Hwy 107
Mailing Address Street Address
Glenville NC 28736 Glenville NC 28736 33606
City State Zip Code City State Zip Code
813-251-0995 _
Phone Fax Number

1. (a) If the Financially Responsible Party is not a resident of North Carolina, please give name and street
address of a North Carolina Agent.
i
Name E-mail ddress
Mailing Address S et Address
ck vyl a-/_ t' L -3 16- -
city
State Zip Code City State Zip Code
-15
Phone Fax Number
(b) If the Financial 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 Financial Responsible
Parry is a Corporation, give name and street address of the Registered Agent.
Name of Registered Agent E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone 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 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 authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any changes in the information provided herein.
Type Print am
Si ure
ac
Title or Authority
v 117 -7
Date
I, -e 6�, LOD,t r a Notary Public of the County of 411111S. Dny qk
State of-i et a, hereby certify that ReV,<= -VR(- tW . ^ appeared personally
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before me this day and being duly sworn acknowledged that the above form was executed b Her.
Witness my ha �00gf t ,seal, this day of J4-PA m�i" 20 ;`1
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State of North Carolina
Department of the Secretary of State
ARTICLES OF CORRECTION
SOSID: 2289235
Date Filed: 10/29/2021 7:03:00 AM
Effective: 10/18/2021
Elaine F. Marshall
North Carolina Secretary of State
C2021 300 00949
Pursuant to §55D-14 of the General Statutes of North Carolina, the undersigned entity hereby submits these Articles of Correction for
the purpose of correcting a document filed by the Secretary of State.
The name of the entity is: OL HAPP'S PLACE LAND LLC
2. On the 18th day of October , 20 21 , the business entity filed:
a. The following described document: Application for Certificate of Authority for Limited Liability Company
-OR-
b. The attached document (Check here-Dif applicable).
3. This document was incorrect in the following manner (sped the incorrect statement and the reason it is incorrect or the manner
in which the execution was defective):
Section 5 / City of registered agent's office was misspelled as "Glanville."
Section 7 did not include the name and address of the Manager of the company.
4. The incorrect matters stated in Item 4 above should be revised as follows or the corrected document may be attached:
Section 5 / the correct spelling of the City of the registered agent's office is "Glenville."
Section 7 / The Name and Address of the Manager are: J. Rex Farrior, III
5914 N Highway 107
Glenville, NC 29736-6402 United States
This the 28th day of October 12021
ame Entity
Si ature
J. Rex Farri Manager
Type or Print Name and Title
NOTES:
1. Filing fee is $10. This document must be filed with the Secretary of State.
2. For effective date of these Articles of Correction, see N.C.G.S. §55D-14.
BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622
(Revised July, 2017) (Form BE-02)