NCC221625_FRO Submitted_20220427

APPENDIX D
FINANCIAL RESPONSIBILITY /OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate a 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, NC Department of Environment, and Natural Resources. (Please type or print and, if question is not
applicable, place N/ A in the blank).
Part A.
1.
2.
3,
4,
5.
Project Name Ecoventures Phase III
Location of land -disturbing activity: County Watauga
City or Township Boone , and Highway/Street
Approximate date land -disturbing activity will be commenced: 3-22-2022
Purpose of development (residential, commercial, industrial, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas):
3.63 - 4 acres
Amount of fee enclosed $ 600.00
Has an erosion and sedimentation control plan been filed? Yes No
Enclosed
8. Person to contact should sediment control issues arise during land -disturbing activity.
Name Chuck Campbell Telephone [phone]
9. Landowner(s) of Record (Use blank page to list additional owners):
Hampton Ecoventures, LLC [phone]
Name(s) Telephone Fax Number
3632 Old US 421 S. 3632 Old US 421 S.
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
16, Deed Book No. 2233 Page No. 161
Part B.
Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use a blank page to list
additional persons or firms):
The J.W.Hampton Company [e-mail]
Namc of Person(s) or Firm(s) E-mail Address
3632 Old US 421 S.
Current Mailing Address
3632 Old US 421 S.
Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip ity State Zip
Telephone [phone] liaxNumber (829) 2%4a '710-i

Z (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 Email 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Cherie Melanie Hampton President
Type or print name Title or Authority
Signature Date
------------------......_........_............_....__-----------------------------------------------------------------------___......_..................-------
I, Ke,yt V T HAr-KKe-0 , a Notary Public of the County of WArA L46A
State of North Carolina, hereby certify that CN101f, 1111EG4N1f HOlPTOAl 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 20 �a'Z
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AFFIDAVIT AS TO STATUS OF LICENSURE
N.C.G.S. 87-1.
FOR THE GENERAL CONTRACTOR TO SIGN:
NAME THE J . W . HAMPTON COMPANY LICENSE NO.
50832
I understand that I am signing this document under oath; I certify that I am making a truthful statement. i
have read G.S. Section 87-1. I have entered into a construction contact where the cost of the undertaking
exceeds $30,000; the contract whether written or oral is in the exact name as listed with the North
Carolina Licensing Board for General Contractors. I am not in partnership (including "joint ventures")
with any unlicensed entity. I certify that I am presently licensed under that name and under that license
number Iisted. My license is active and in good -standing — I have filed all necessary renewal forms with
the North Carolina Licensing Board for General Contractors. I am not presently under any disciplinary
order issued by the North Carolina Licensing board for General Contractors which disqualifies me for a
building permit. I understand that the unlicensed practice of general contracting is a criminal offense
under G.S. Section 87-13, and that I may be sued by the North Carolina Licensing Board for General
Contractors for an injunction if I practice without a license as required by law. I also understand that,
under North Carolina caselaw, an unlicensed practitioner may be barred from recovery of any civil
damages if the job owner refuses to pay me.
I have been informed that any authority issuing a building permit to an unlicensed contractor where a
license is required may be found guilty of a misdemeanor, and I certify that this Department may rely on
my statement as a truthful statement regarding the status of my license.
FOR TIME OWNER/APPLICANT TO SIGN:
NAME
TELEPHONE NO.
I understand that I am signing this document under oath; I certify that I am making a truthful statement. I
have entered into a construction project where the cost of the undertaking exceeds $30,000;1 have read G.
S. Section 87-1. I certify that I am not allowing an unlicensed general contractor to perform the duties of a
general contractor, which, I understand from reading G.S. Section 87-1 include construction
superintending and managing in addition to, among other things, signing written contracts. I intend to
retain the finished house (or other projects) exclusively for my own use, and to be occupied by me or my
family for a minimum of one year after completion. I am not building a "speculation" project with the
intention of selling the project once it is completed. I understand that building a "spec" project without
proper licensure is a violation of G.S. 87-1 and G.S. 87-13; this may be a criminal offense. Also, I
understand that under G.S. Section 87-15.5, the "Homeowner's Recovery Fund", no homeowner acting as
a general contractor has any right of recovery. I will be on the job site for all required
inspections.
SWORN TO AND SUBSCRIBED BEFORE��i�rll����� �X✓
THIS THE aZ DAY OF �B�UAI� ' i�pR4y V/i�
�`� Signature
NOTARY Z=
NOTAY PUBLIC PUBLIC
MY COMMISSION EXPIRES
3�lSI�s',f ;NrY �oa��� `.
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WATAUGA COUNTY Department of Planning & Inspections
126 Poplar Grove Connector Suite 201 • Boone, NC 28607 s Phone:[phone] • Fax:[phone]
GRADING PERMIT
APPLICATION
ALL APPLICANTS ARE RESPONSIBLE FOR OBTAINING ANY STATE
OR FEDERAL PERMITS IF APPLICABLE.
DATE: 02/ 22/ 22
PROPERTY OWNER: Hampton ECoventures, LLC
ADDRESS: 3632 Old 421 S.
PROPOSED PROJECT LOCATION: US H WY 421 S.
TAX PARCEL #: 2931817745000
PHONE: $( 2$) 264-7103
CITY Boone STATE NC ZIP 28607
GRADING CONTRACTOR: The J. W. Hampton Company LICENSE#: 50832
ADDRESS: PO Box 1997, 3632 Old 421 S.
PHONE: [phone]
PURPOSE OF GRADING: Level Site ESTIMATED COST: $
HYDROSEEDING?
AREA TO BE GRADED: (approx acreage) 3.63 = 4 acres HANDSEEDING ?
NUMBER OF FEET OF STREAM(S) IMPACTED? (If applicable): NIA
EXPECTED START DATE: 3 / 22 / 22 EXPECTED COMPLETION DATE: 3 / 22 / 25
The tuidersigned agrees to conform to all applicable laws of the County of Watauga
and the State of North Carolina: and further states that all statements made hereon are true.
APPLICANT SIGNATURE .t�V DATE SIGNED
PERMIT FEES $
PERMIT DATA REVIEWED BY:
EROSION PLAN REQUIRED?
[aWAI1RIk�LIKI � •
PERMIT ISSUED BY:
OFFICIAL USE
PAID?
YES/NO
PERMIT VALID UNTIL:
DATE
DATE:
LICENSED CONTRACTOR REQ?
PLAN APPROVED BY:
DATE ISSUED:

AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE
N.C.G.S. § 87-14
The undersigned applicant for Building Permit # being the
F Contractor
C I Owner
F, Officer/Agent of the Contractor or Owner
do hereby aver under penalties of perjury that the person(s), firm(s) or corporation(s)
performing the work set forth in the permit:
has/have three (3) or more employees and have obtained workers' compensation
N insurance to cover them,
has/have one or more subcontractor(s) and have obtained workers' compensation
insurance covering them,
has/have one or more subcontractor(s) who has/have their own policy of
workmen's compensation covering themselves,
F� has/have not more than two (2) employee and no subcontractors,
while working on the project for which this permit is sought. It is understood that the
Inspection Department issuing the permit may require certificates of coverage of
workers' compensation insurance prior to issuance of the permit and at any time during
the permitted work from any person, firm or corporation carrying out the work.
Firm Name: THE J.W. HAMPTON COMPANY
M.
Title: PRESIDENT
Date: 02/22/2022

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION
Property Deed:
Book 2233, 2233
Page 161,153
Parcel Id: 2931817745000
Street Address: US Hwy 421 S
Property Owner: Hampton Ecoventures
The undersigned, registered property owners of the above noted property, do hereby authorize
Agent of BREC, PA —
to act on my behalf and take all actions necessary for the processing, issuance and acceptance
of this permit or certification and all standard and special conditions attached.
Property Owner's Address (if different than property above):
3632 Old 421 S
Boone NC 28607
We hereby certify the above information submitted in this application is true and accurate to
the best of our knowledge.
Authorized Signature
Date: a- -- a;k - ex) ?r 2)-
Cherie Melanie Hampton, Managing Member
Print — Name, Title

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled led or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
❑x I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
® The information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
x1 I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times,
0 I hereby request coverage under the NCGO10000 General Permit and understand that coverage underthis
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): Ecoventures Phase III
Specific Lot Numbers (must match Alb):
Ily Responsible Organizational Entity (must match B1): The J.W. Hampton Company
Legally Responsible Person (must match B2 & B3): Cherie Melanie Hampton
Title of Legally Responsible Person (must match B3b): President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: [phone]
�Oy1n.�J
Signature of Legally Responsible Person or Authorized Individual
a - as -aC)
Date
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 permit.