NCC220327_FRO Submitted_20220126

BUNCOMBE COUNTY
PLANNING DEVELOPMENT<. [phone] - [e-mail]
www.buncombecounty.org/planning
INSTRUCTIONS: All sections must be completed. Section E must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FOR AN
EROSION CONTROL PERMIT
CASE NUMBER:
A. Existing Property Information
PIN (Numbers): 0609551146 Project Name: Givens Highland Farms Campus Redew
Latitude: 35.614913 Longitude:-82.348894 _ Amount of fee enclosed: $ 4,462.50
Project Location - Highway/Street: 200 Tabernacle Road / Oak Leaf Terrace, Black Mountain NC, 27811
Proposed Use: ❑ Single Family Residence m Multi -Family ❑ Vacation Rental ❑ Commercial/Industrial/Other ❑ Other
Proposed Disturbed Area (Include offsite borrow and waste areas): 8.52 acre(s)
B. Contact Information — Financiatly Responsible
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership". This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact. The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and. Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as the penalties and resources available to the County in the event of violation of the Ordinance, including revocation of the Land
Disturbing Pen -nit and al] building permits issued in connection with the project covered by the application.
Name of Business: Givens Highland Farms Name of Applicant: Ken Kramer
Mailing Address: 200 Tabernacle Road, Black Mountain NC, 27811
Street address: same as
E-mail address: kkramerOuivenshighlandfarms.org
Telephone: [phone] Cell: Fax: [phone]
C, Landowner(s) of Recotd,
Name of Landowner(s) of Record: Givens Hi hland Farms LLC
Mailing Address:
Recorded in Deed Book No: 5045 Page: 1294
D. Contact Information —North Carolina Agent ip
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person financially responsible
is not a resident of North Carolina, a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the plan, the Act, this ordinance, or rules or orders adopted or issuedpursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent:
Mailing Address: .�n��_f /y�
E-mail address:,
Telephone: e Cell: / Fax:
Signature: Date: // `.I rZ
I, the undersigned, attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party, responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project. I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County in
the event of violation of the Ordinance. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: Title: -Drrtel6r-
Signature. Date:o?g�?�
a Notary Public for the County of
A'
State of / � L �1 ! L&r U!r(.%�l a hereby certify that �� /� _ ,.r er
appeared before me this day and under oath acknowledged that the above form was executed by him and is corr�6glirs
knowledge and belief.
Witness my hand and seal, this day of200 R y
I� G
My Commission Expires ou
OFFICE Review fee;, PennitNo.: Cheek No: „
USE v -* ,. �M*. . ;, ..
Date Fail: Received by:
The County of Buncombe does not discriminate on the basis of'disability in the admission or access to, or treatment or employment in,
its programs or activities. Requests for appropriate auxiliary aids and services, when necessary to gffer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services, programs, or activities, may be made by contacting
Buncombe County Erosion Control, [phone]. Buncombe Coumy's TDD number is [phone].