NCC223936_FRO Submitted_20221123

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Northside Estates
2. Location of land -disturbing activity: County Madison City or Township Mars Hill
Highway/Street US Hwy 19 Latitude(d ,;852054 Longitude(d 4)i7eFees
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0 ac
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Frank Rogers E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CMH Homes, Inc
Name Phone: Office #
5000 Clayton Rd
Current Mailing Address
Maryville, TN 37804
City
State Zip
Current Street Address
Mobile #
City State Zip
10. Deed Book No. 752 Page No. 212 Provide a copy of the most current deed.

(c) If the Financially Responsible Parry is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
C.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
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Type or print name Title or Authority
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Signature Date
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a Notary Public of the County of lA me
State of North Carolina, hereby certify that V-G(rU4- k04R&L appeared personally
before me this day and being duly swom ack
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owledged that th bove form was executed by him/her.
Witness my hand and notarial seal, this ~ day of , 20 ata
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Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(res).
CMH Homes, Inc
Company Name
1123 Smokey Park Hwy
Current Mailing Address
[e-mail]
E-mail Address
1123 Smokey Park Hwy
Current Street Address
Candler, NC 28715 Candler, NC 28715
City State Zip City State Zip
Phone: Office #
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 919-944-4780 Mobile #
Name of Individual to Contact (if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip
Phone: Office #
City State Zip
Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

Carolinas Engineering
and Development, PA
11 Duke Street
Asheville, NC 28803
MikeTAndersonPE(Mizmail.com
828-582-8970
May 18, 2022
To Whom it May Concern
Re: North Side Estates
I, the current landowner/managing partner of the property identified below, hereby authorize
Carolinas Engineering and Development, PA (CED) to act on my behalf as my agent during the processing
of permits to impact Wetlands and Water of the US subject to Federal jurisdiction under Section 404 of
the Clean Water Act and/or apply for Land Disturbance Permits through NCDEQ.
Additionally, I authorize representatives of the Wilmington District, US Army Corps of Engineers, and
representatives of NCDEQ to enter upon the property herein described for the purposes of conducting
onsite investigations associated with the permits requested.
Property Owner of Record CMH Homes. Inc
Property Owner Address 1123 Smokev Park Hwy. Candler, NC
Phone Number [phone]
Email Address [e-mail]
Property Location US Hwy 19 Madison Countv 35.852054. -BM91407
Owner/Managing Partner Signature
Owner/Managing Partner Name
DateZ--
828-582-8970 11 Duke St. Asheville, NC 28803 MikeTAndersonPEOW¢mail.eom NC Firm C-4902
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