NCC223522_FRO Submitted_20221017

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FINANCIAL RESPONSIBILIiYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on '/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 Cullasaja Golf Course Renovation
2. Location of land -disturbing activity: County Macon � City or Township Highlands
Highway/Street�4 E Latitude 35.0706 , Longitude ___83•1682 _
3. Approximate date land -disturbing activity will commence: 10/17/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 18.15
6. Amount of fee enclosed: $ 1 ,900 The application fee of $100.00 per acre -
is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been ailed? Yes NEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tom Nelson I E-mail Address [e-mail]
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cullasaja Club, Inc 828-526-3531 828-526-3560
Name Telephone Fax Number
1371 Cullasaja Club Dr 1371 Cullasaja Club Dr
Current Mailing Address Current Street Address
Highlands, NC 28741 Highlands, NC 28741
City State Zip City State Zip
10. Deed Book No W-23 page No. 743 Provide a copy of the most current deed.
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.
Cullasaja Club, Inc I [e-mail]
Name E-mail Address
1371 Cullasaja Club Dr 11371 Cullasaja Club Dr
Current Mailing Address Current Street Address
Highlands, NC 28741 Highlands, NC 28741
City State Zip City State Zip
rev 103023

Telephonel28-526-3531,,,..._ _Fax Number.28-526-3560
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:
Name E-mail Address
Current Mailing Address
City State Zip
Telephone)
Current Street Address
City State Zip
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:
Tout Nelson [e-mail]
Name of Registered Agent E-mail Address
1371 Cullasaja Club Dr
Current Mailing Address Current Street Address
Highlands, NC 28741
City State Zip City State Zip
Telephone [phone] j 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.
Chris Conner General Manager/ COO
Type or pr'nt name Title or Authority
a
Signature Date
'1r22.t �, a Notary Public of the County of "'
State of North Carolina, hereby certify that ea'c— 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 =, 2
My commission expires)
MONA R HUMPHREY
Notary Public, North Carolina
Macon County
`.7y Commission Expires
-----May 01,2027