NCC221860_FRO Submitted_20220516

MENDEk�SON _�- ?
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
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 Environment and Natural Resources. (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 �g M 0 P"h film
2. Location of land -disturbing activity: County w %A& City or Township
Address of Project:VU Latitude 35.351 Zb I Longitude — I q1
a k00i
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): T's
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 4100 a Fee Schedule FY 2018-2019 is available on
Water Resources at link https;/hWwW.hendersoficount!inc.gov/waterresources/page/algproved-
fees fy-2018-2019-0.
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 od 44 @—o-T <VEP.W4,y E-mail Address '-,pCa d6�W%n- eta %Up— ,LAM
PC) Ba,e toO a�CV;ewC a$ ��
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 19 Z - (o Z18m B 9 9 Cell # Jeol '- ? 111
9. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must match
Hende.rson County Courthouse Dared records information or provide a recorded deed:
Name ` Telephone Fax Number
Current Mailing Address Current Street Address
� `To0i*A WC. N � � _ A �_ a0 /IC— ZBOS4
City State Zip City State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

10. Deed Book No. Page No. 2.06 Provide a copy of the most current deed.
Part B.
Person(s) or firms who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) NOTE: The signature of a
corporation, or LI-C must be a listed member on the formation documents on file with the
state office at httEs://www.sotne.gov/search/indext
Name log � v, g br E-mail Address
b ('oG 0rdi
Current Mailing Address Current Street Address
V.�3"Te W Q C� ZB'730
City State Zip
Telephone ,, ®16m 3 j q / 1) 1-9
City State Zip
74.7" 71-11
2. (a) If the Financially Responsible Party is not a resident of Borth Carolina, give name and street.
address of the designated North Carolina Agent:
Name E-mail Address
Current Mailing. Address
City
Telephone
State
Zip
Current Street Address
City
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business
under an assumed name, attach a co2y of the. Certificate of Assumed Name. If the Financially
Responsible Party's a Corporation, give name and street address of the Registered Agent:
Rare
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State Zip City
State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

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.
Typeir pr
Ir�ll L�►�� - -Tjg� Title or Authority
�.
Date
1, �. Q , a Notary Public of the County of
State of North Carolina, hereby certify that ®Iappeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this tl4k
day of , 20
Notary
®eal2
Z" My commission expires ,D•27- z's
dp Iry PUBV
,sNe'9 4BE gGQ°as`�a
City of Hendersonville FRO -doe Revised 6-19-2018