NCC220701_FRO Submitted_20220214

JACXS'ON COUNTY PCRMITTINC & CODE, E,NFORC , ME, NT RECEIVE -
Land Disturbance: One -•Half (I/2) or more Acre lSfortnwaler Insfallallon
Tittaiteial Respoitsihllify/OtPnerslilp Toritt DEC 14 207
Sylva Office: M S'cofly Creek Rood, Smile 20S, Phone: [phone]SMI Fax: [phone]
Cashl ers Office: 357 Prank Ailett Roars, Phone: 828-74S-68S4 / Fax: 828-74S-6867
No person tnay initiate a land -disturbing activity and/or stounwater installation on more than one -Half acre as covered by the
Act before this forth and an acceptable erosion and sedimentation control/storntvvatet plan have been completed and
approved by the Jackson County Office of Permitting & Code Enforcement. If work is started without an approved pertnit
yoku 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
tiffamYclualls tt.jtucicsot�utc.csr or jamiebaunxg triter rt?�:LCILsolltic.orl,,
• A surety bond is requited for any disturbance of five (5) acres of more
Part A
1, Project Name; Gates Property -115 Haywood Road Grading __.. _ PIN 7631-46-8744 i -4 to'-:5 I - Ob- a 36 3
Z. Location of land -disturbing activity/stounwater installation; (City or Township) Dillsboro
Highway/Street Haywood Road Latitude 35.370 LoDgitude-83.245
3. This project will require the review of the following: ❑f Etosion Control ❑Stoirnwater
Is this project within a regulated district?❑No ❑✓ Yes — Disttict: Town ofDillsboto
4. Approximate date work will begin onsite: 12 30 21
5. Purpose of development (residential, comruereiat, industrial, etc,) Residential
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.II70
7. Amount of fee S 1,200.00 FOR OFFICE USE: Received? (uutiai/date) cSY 1 I mil• �`i" caC f
8. Has an erosion & sedimentation control/storm-water plan been fled? ❑No []Yes WIRuctosed
9. Person to contact should issues arise during land -disturbing activity/stounwater installation:
Name David GatesE-mall Address vu,stillwelt(a?sti(Iwellett�ineerltz .net
Phone 828,399,0132 Cell 828.506.3991 Fax N/A
10. Landownexs(s) of Record (Use blank page to list additional owners) Deed Bk/Pg 2313 / 254 (Provide a copy)
Name IRavid and Cattuateita Gates Phone 28.M.0132 Fax N/A
Current Mailing Address PO Box 848 Dillsboro NC 28725
Part B
Company(ies) or firm(s) who are fituancially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible patties 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.
David and Catmaletta Gates
Name
PO Box 848
Mailing Address
Dillsboto NC 28725
City State Zip Code
828.399.0132
Phone
w,stillwell stillvvellett tkeetii ;.:set t C ` P
E-mail Address 2-1
-1 } „�fj r
52 East Hemlock Street [
StrectAddress
Diltsboto NC 28725
City State Zip Code
N/A
Fm Number 150 PMR13

1. (a) If the Financially Responsible Party is not a resident of North Carolina, [Tease give name and street
address of a North Carolina Agent, RECEIVEr'
DEC i M1
Name E-mail Address
Mailing Address Street Address RECEIVED
DEC 14 MI
City State Zip Code City State Zip Code
phow: } NX Nuslibev
(b) If the Financial Responsible batty is a Partnerslup or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financial Responsible
Patty 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
Prone Fax Number
The above information is true and correct to the best of niy knowledge and belief and was provided by me under
oath. (This form swast be signed by Financially Responsible Person if an Individual or his attorney -in -
fact, or if not an individual, by an officer, director, partner, of registered agent with authority to execute
instruments for the Financially Responsible Person), I agree to provide corrected information should there
be any changes hi the information provided herein.
Type or Print Name
Signature
Title or Authority
1:2-.1q
Date
a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before the this day and being duly sworn acknowledged that die above form was executed by 11hn/
t.)
Witness my hand and notarial seal, this lt'Pl- y of t G� � 2
JOHN C PARKS
Notary Public, North Carolina
16 t ackson County
tVlfj� ommisslon Expires
June 07; 2022
Notary /
/
My Commission Expires D