NCC222063_FRO Submitted_20220613

o4.SON coG� JACKSON CO UNTY PERMITTING & CODE ENFORCEMENT
Land Disturbance: One -Half (1/2) or more Acres/Stormwater Installation
- Financial Responsibility/Ownership Form
gyp' �s`T Sylva Office: 538 Scotts Creek Road, Suite 205, Phone: [phone] / Fax: [phone]
9ry C p p0�� Cashiers Office: 357 Frank Allen Road, Phone: [phone] /Fax: [phone]
No person may initiate a land -disturbing activity and/or Stormwater installation on more than one-half acre as covered by the
Act before this form and an acceptable erosion and sedimentation control/stormwater plan have been completed and
approved by the Jackson County Office of Permitting & Code Enforcement. If work is started without an approved permit
your permit fee will be doubled.
+ Please type or print, and if any question is not applicable or the e-mail and/or fax information unavailable,
place N/A in the blank.
+ Submit three (3) copies of the plan, a narrative, and the appropriate fee; please contact our office for an
accurate fee calculation before submitting paperwork. For fee calculation call 828-745-6850 or e-mail
[e-mail] or [e-mail].
+ A surety bond is required for any disturbance of five (5) acres or more
Part A
1. Project Name: South River Road Roadway Construction PIN 7640- (46-8228, 57-9049)
2. Location of land -disturbing activity/stormwater installation: (City or Township) Webster
Highway/Street 520 South River Road Latitude 35.342 Longitude-83.212
3. This project will require the review of the following: ✓❑ Erosion Control ❑Stormwater
Is this project within a regulated district?❑No ✓❑Yes— District: Jackson County
4. Approximate date work will begin onsite: 5/16/22
5. Purpose of development (residential, commercial, industrial, etc.) Residential
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4.98
7. Amount of fee $1,450.00 FOR OFFICE USE: Received? (initial/date)
8. Has an erosion & sedimentation control/stormwater plan been filed? ❑No ❑Yes Enclosed
9. Person to contact should issues arise during land -disturbing activity/stormwater installation:
Name Paul Lewis E-mail Address N/A
Phone [phone] Cell 828.269.1117 Fax
10. Landowners(s) of Record (Use blank page to list additional owners) Deed Bk/Pg 2322/1667 (Provide a copy)
Name Byers Construction & Development, LLC Phone [phone] Fax N/A
Current Mailing Address [e-mail]
Part B
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.
Byers Construction & Development, LLC [e-mail]
Name E-mail Address
47 Mint Springs Rd 47 Mint Springs Rd
Mailing Address Street Address
Pittsboro NC 27312 Pittsboro NC 27312
City State Zip Code City State Zip Code
910.367.8760 N/A
Phone Fax Number

1. (a) If the Financially Responsible Party is not a resident of North Carolina, please give name and street
address of a North Carolina Agent.
Name E-mail Address
Mailing Address Street Address
City State Zip Code City State 'Lip Code
Phone Fax Number
(b) If the Financial 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 Financial Responsible
Parry is a Corporation, give name and street address of the Registered Agent.
Name of Registered Agent E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone
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 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 authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any changes in the information provided herein.
Brenten Byers
Type or Print Name
Managing Member
Title or Authority
0xI/3o/2Z
Date
1, %t C! lt',4and tCt P1 h1P r :l 5 a Notary Public of the County of O be ahayn ,
State of North Carolina, hereby certify that _ 3 r e ni en Pit JefS appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Her.
IH
Witness racy hand and notarial seal, this day of 1 20 2 Z+ .
Nota
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My Commission Expires
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