NCC221055_FRO Submitted_20220315

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 N/A in the
blank.)
Part A.
1. Project Name Providence Walk
2. Location of land -disturbing activity: County Henderson City or Township Hendersonville
Highway/Street N. Main Street ;SR-15031 Latitude 35.3373 Longitude-82.4591
3. Approximate date land -disturbing activity will commence: 2/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.60 AC
6. Amount of fee enclosed: $ 4,400 . The application fee of $300.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 7.2-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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Travis Fowler E-mail Address
Telephone [phone]
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Providence Walk, LLC
Name
542 S. Caldwell Street
Current Mailing Address
Brevard NC 28712
828-884-7934
Telephone
542 S. Caldwell Street
Current Street Address
Brevard
Fax Number
NC 28712
City State
Zip
City State Zip
10. Deed Book No.
Page No.
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
Providence Walk, LLC
Name
E-mail Address
542 S. Caldwell Street
542 S. Caldwell Street
Current Mailing Address
Current Street Address
Brevard NC
28712
Brevard NC 28712
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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 print name
�-7>
Signature
Title or Authority
Date
/,A.LI5 , a Notary Public of the County of G CA, t` CJ_
State of North Carolina, hereby certify that i -61V � S rc>L'� f r _ 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 day of AnUa��. 20
TABE7HA A MCCOMBS Notary
NOTARY PUBLIC
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Commission Expires:09/28/202G My commission expires