NCC221272_FRO Submitted_20220413

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 NIA in the blank.)
Part A. Blue Ridge Mountain Sky Soil Erosion Sediment Control Plan
1. Project Name g y
Z Location of land -disturbing activity: County Polk City or Township White Oak
Highway/Street Ponder Rd Latitude35.29484 Longitude-82.07837
3. Approximate date land -disturbing activity will commence: Writer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.), Agricultural
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): +1- 39 Acres
8, Amount of fee enclosed: $2,535.00 . The application fee of $55.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee Is $585).
7. Has an erosion and sediment control plan been filed? Yes x No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joel Lenk, 4uible & Associates, P.C. E-mail Address [e-mail]
Telephone [phone] cell # same Fax # NA
9, Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Ridge Mountain Sky, LLC 828-388-4568 NA
Name
102 Rockwood Drive
Current Mailing Address
Hendersonville, NC 28792-9322
City
10. Deed Book No. 365
Telephone
Current Street Address
State Zip City
Page No.713
Fax Number
State
Zip
Provide a copy of the most current deed.
Part B.
I. 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 fisted as the financially responsible party.
Blue Ridge Mountain Sky, LLC [e-mail]
Name
102 Rockwood Drive
E-mail Address
Current Mailing Address Current Street Address
Hendersonville, NC 28792-9322
City
State Zip City State Zip
Telephone 828-388"4568 Fax Number NA

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:
William D. McCraw [e-mail]
Name
102 Rockwood Dr.
Current Mailing Address
Hendersonville, NC 28792
City
state Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
Fax Number NA
(b) If the Financially Responsible Party is a Partnership or other parson 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:
William D. McCraw [e-mail]
Name of Registered Agent
102 Rockwood Dr.
Current Mailing Address
Hendersonville, NC 28792
City
E-mail Address
102 Rockwood Dr.
Current Street Address
Hendersonville, NC 28792
State Zip City
Telephone [phone] 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.
William D. McCraw
Type or print name
Signature
Member/Manager
Title or Authority
3/3/2021
Date
I, Kay Jones , a Notary Public of the County of Henderson
State of North Carolina, hereby certify that William D. McCraw appeared
personally before me this day and being duly swam acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 5th day of March , 2021
K AY JOMES
NOTARY PUBLIC Notary
HENDERSOWCQIIHTY, NC
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My commission expires