NCC222746_FRO Submitted_20220812

BUNCOMBE COUNTY
PLANNING & DEVELOPMENT
[phone] • [e-mail]
www.bu n co m beco u nty.orgip lann i ng
INSTRUCTIONS: All sections must be completed. Section F must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FOR AN
EROSION CONTROL PERMIT
CASE NUMBER:
PIN (1Numbers).972179699800000; 972179531800000; 972270819000000 Project Name: AUTOCAMP ASHEVILLE
Latitude: 35.67732 Longitude:-82.61217 Amount of fee enclosed: $
Project Location - Ilighway/Street: Old Marshall Hwy
Proposed Use: ❑ Single Farnily Residence ❑ Alidli-Fanuly X Vacation Retrial ❑ ConmrercirrllhrdrisiriallOther ❑ Other
Proposed Disturbed Area (Include offsire borrow and waste areas): 7.3 —acre(s)
B.
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion contra] plans shall be
accompanied by a notarized statement of financial responsibility and ownership'. This statement shall be signed by the person
financially responsible Far the land disturbing activity or his attorney in fact. The undersigned states that he/she is the person
financially responsible for land disturbing aclivity described in this application and acknowledges receipt of copy of the County of
Buncombe Soil Erasion and Sedimentation Control Ordinance and that he/she has 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, including revocation of the Land
Disturbing Permit and all building permits issued in connection %with the project covered by the application.
Name of Business: AC Asheville LLC Name ofApplicanl: Shawn Tnnlay
Mailing Address: PO Box 92251 Santa Barbara, Ca. 93190-2251
Street address: 121 East Mason Street Suite B-Santa Barbara, Ca. 93101
E-mail address: shawn @autocamp.com
Telephone: Ceti: 925-628-5050 Fax: J
Name of Landovner(s) of Record: AC Asheville LLC
Mailing Address: PO Box 92251 Santa Barbara, Ca. 93190-2251
Recorded in Deed Book No: 6065 Page: 518
D. Contact Information — North Carolina Agent (VApplicable)
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person financially responsible
is not a resident of North Carolina, a North Carolina agent must be designated in the statement for the purpose crreceiving notice of
compliance or non-compliance with the plan, the Act, this ordinance, or rules or orders adopted or issued pursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent: nd�
,,44 6LA. 1 �S� Aro &CSC, -- �7 � �r�
Mailing Address: U PA f\11�, i! C %fed A s6yllle AjG
E-mail address: 5 r Qrai� w r
Telephone: 7 Cell: Fax:
Signature: Date: 10• ZIlT ao2 {
I, the undersigned, attest that I am the financially responsible party or an authorized representative %vith signatory authority for the
financially responsible party, responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project. I acknowledge receipt o f a copy ofthe County or Buncombe Soii Erosion and Sedimentation Control
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the Count), 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.
Name: Shawn Tooley IrTitle: VP of Construction
Signature: Dale:11/2112�
I. Ian Barrett Nelson aN❑lary Public for th❑ County of Virginia Raarh
State of Virginia hereby cerlify that ShaxArn Tnnla�/ 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.
Witness my hand and seal, this jSt day of December 20 21
0- aa��N.,, Notary.
Notarized online using audio -video communication
My Commission Expires 1? /71 /90? S
„ .
OFFICE Review Fee: S Permit No.: Check No:
USE Date Paid: Received by: Date Issued:
The County of Buncombe does not discriminate on the basis of disability' in the Admission or access to, or treatment or employment in,
its programs or activities. Requests for appropriate arcriliarn+ aids and services, when necessary to offer a person iv 0h a disability all
equal opportunity to parricipate in ar enjoy the benefas of County services, programs, or activities, nary be made b}7 contacting
6unconthe County Erosion Canrrol, [phone]. l3ancombe Counn,'s TDD number is [phone].