NCC220571_FRO Submitted_20220209

Appendix D Ownership/Financial Responsibility Form
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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. Submit the completed form to the appropriate
Regional Office. (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.
1. Project Name The Bluffs at Blowing Rock
2. Location of land -disturbing activity: Cc
City or Townshi
Highway/Street US 221 Latitude 36 07' 34" N Longitude 81 42' 55" W
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10
6. Amount of fee enclosed: $ 1500 ($150/ Acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed__
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Jay Harrill
Telephone [phone] Cell #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J3M, LLC 828-963-7600
Name Telephone
133 Echota Parkway
Current Mailing Address
Boone NC 28607
City State Zip
Fax Number
133 Echota Parkway
Current Street Address
Boone NC 28607
City State Zip
10. Deed Book No. 2201 Page No. 211 Provide a copy of the most current deed.
Part B.
1. 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.
J3M, LLC [e-mail]
Name E-mail Address
133 Echota Parkway 133 Echota Parkway
Current Mailing Address Current Street Address 28607
Boone NC 28607 Boone NC
City State Zip City State Zip
243

Telephone [phone] Fax Number.
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'.
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copyof 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
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 or p ' t na Title or Authori
Sign re Date
I, G a Notary Public of the County of Gt�Li C((�-
State of North Carolina, hereby certify that /TGi rr, �� appeared
personally before me this day and being duly sworn ac nowledged that the above form was executed
by him. �/ f!4
Witness my hand and notarial seal, this / day of WIP h4 20 2�
��1llllt/l; /
Not ry
Seal • <N�i�
i 3G-fARY •� _ My commission expires C �9 ZDZZ
�• PUBLIC • V =