NCC221265_FRO Submitted_20220405

BUNCOMBE COUNTY
PLANNiNG & DEVELOPMENT
x., ...-30 - [e-mail]
www.buncombecounty,org/planning
INSTRUCTIONS: All sections must be completed. Section D must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FORA
STORMWATER PERMIT
CASE NUMBER:
ProjectName: The Village
PIN (Numbers): 9731-76-1678
Latitude: 35.666987 Longitude: -82.577839 Amount of fee enclosed: s 1)816.50
Project Location - Highway/Street: Old Home Road
Proposed Use: n Single Family Residence ❑ Multi -Family 8 Vacation Rental ❑ Commercial/Industrial ❑ Other
Proposed Disturbed Area (Include offsite horrow and waste areas): 3.46 acre(s)
B. Applicant Contact Information
Name of Applicant- Michael Parrish State ofRnminesc R"ic_trntion /ifnpplicohln).-
Applicant's Point of Contact (for official correspondence): Michael Parrish
Mailing Address: 21 Carolina Sunset Pass, Ashville, NC 28804
Street address: 21 Carolina Sunset Pass, Ashville, NC 28804
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
Name of Landowner(s) of Record: Michael Parrish
Mailing Address: 21 Carolina Sunset Pass, Ashville, NC 28804
Recorded in Deed Book No: 6016 Page: 0245
Name of Landowner(s) of Record:
Mailing Address:
Recorded in Deed Book No: Page:
Note: If applicant is not landowner of record, provide executed Buncombe County Stornniater Agent Authorization Form
1, 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 installation, operation, and maintenance of the stormwater controls until ownership
is conveyed for the above referenced project. I acknowledge receipt of a copy of the County of Buncombe Stormwater Management
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.
Financially Responsible Party: M r i
Signature: Date:- 1 C — 6 — 2 1
Name: Title: UuJ�
I,_Jf/YyVl a Notary Public for the County of 01A, i WrM 11-6
State of iyoy nn r pa c> I i vtce� hereby certify that Um l Lk ct A PG V Irt s h _personally
appeared before me this day and under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge and belief. /�
VJiiueas my haul a,il seai,'1Lis 'Say uS 0( 4110 �V , 20
Notary
Tem Rau, My Commission Expires -2tX0, a �.
NOW public
Buncombe County, NC
My canutiraiott acpins^7 ��
OFFICE Review Fee: $ Permit No.: Check No:
USE Date Paid: _ Received by: Date Issued:
The Count), of Buncombe does not discriminate on the basis of disability in the admission a• access to, or treatment or employment in,
its programs or activities. Requests for appropriate auxiliary aids and services, when necessary to offer 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 County's TDD number is [phone].