NCC220934_FRO Submitted_20220302

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the
Henderson County. Submit this form to: 240 Second Avenue East, Hendersonville, NC 28792. (Please type
or print and, if the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the
blank.)
Part A.
1. Project Name The Landings of Flat Rock
2. Location of land -disturbing activity: County Henderson City or Township Hendersonville
Highway/Street S. Allen Rd Latitude 35.301793 Longitude-82.415151
3. Approximate date land -disturbing activity will commence: Feb. 1st, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8 Acres
6. Amount of fee enclosed: $ $2,600.00 The application fee of $300.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a T2-acre application fee is $300.00
x 8 = $2400.00 plus $200.00 plan review fee = $2600.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
A
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Corey Mabus E-mail Address [e-mail]
Telephone [phone] Cell # 910-728-5714
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Henderson Propco, LLC
Frannmsrn T_ Morales
Name Telephone
Fax Number
PO Box 26255 101 S. Stratford Road, Suite 210
Current Mailing Address Current Street Address
Winston Salem, NC
City
State
27114 Winston Salem,
Zip City
NC 27104
State
Zip
10. Deed Book No. 3619 Page No. 669-673 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.
Carolina Commercial Contractors, LLC [e-mail]
Name
PO Box 159
Current Mailing Address
E-mail Address
1600 Colon Road
Current Street Address
Sanford, NC 27331 Sanford, NC 27330
City State Zip City State Zip
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 copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
W. Carter Keller [e-mail]
Name of Registered Agent E-mail Address
PO Box 159 1600 Colon Road
Current Mailing Address Current Street Address
Sanford, NC 27331 Sanford, NC 27330
City State Zip City State Zip
Telephone [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 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.
W. Carter Keller
Type or print name
y-1
Signature
Managing Member
Title or Authority
/e..,;
Date
-----------------------------------------------------------------------------------------------------------------
a Notary Public of the County of I f e-1
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this lU-day of N �VVf 1lX_JP�✓ , 20 _
CN ;
';��• �� a -.e, P�q? 0 Notary
W ? �j
Doti°' '� = My commission expires 41
0� ..........