NCC230727_FRO Submitted_20230320

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JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Land Disturbance: One -Half (1/2) or more Acres/Stormwater Installation
Financial Responsibility/Ownership Form
Sylva Office: 538 Scotts Creek Road, Suite 205, Phone: [phone] /Fax: [phone]
Cashiers Office: 357 Frank Allen Road, Phone: [phone]/Fax; 828-745-6867
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
1i£fmMualls4acksonnc.orgor'amiebaum amera'acksorinc.or .
• A surety bond is required for any disturbance of five (5) acres or more
Part A
1. Project Name: Wade Hampton - Golf Maintenance Facility PIN 7581-13-5823, 7581-30-1692
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Location of land -disturbing activity/stormwater installation: (City or Township) Casbiers
Highway/Street NC HWX 107 (Cherokee TraceL Latitude 35.084722 Longitude -83.068312
3. This project will require the review of the following: Zrosion Control F—Itortnwater
Is this project within a regulated district? �o [:Jes — District:
4. Approximate date work will begin onsite: Apt 2023
5. Purpose of development (residential, commercial, industrial, etc.) Commercial
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.7 ac
7. Amount of fee 300 FOR OFFICE USE: Received? (initial/date)
8. Has an erosion & sedimentation control/stormwater plan been filed? Do Des �nciosed
9. Person to contact should issues arise during land -disturbing activity/stormwater installation:
Name Eric 5homaker E-mail Address lfcourse wadeham ton e.com
Phone [phone] Cell Fax
BK1879.PG 291-294 &
10. Landowners(s) of Record (Use blank page to list additional owners) Deed Bk/Pg BK 2183,PG 871-872 (Provide a copy)
Name Wade Hampton Golf Club Inc. Phone [phone] Fax
Current Mailing Address, 68 Golf Drive, PO Box 1920 Cashiers, NC 28717
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.
Wade Hampton Golf Club Inc.
Name
68 Golf Drive, PO Box 1920
Mailing Address
Cashiers NC 28717
City State Zip Code
[phone]
Phone
golfcoursenawadehamptongc.com
E-mail Address
2044 Cherokee Trace
Street Address
Cashiers NC 28717
City State Zip Code
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 Zip Code
Phone Pax 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
Party 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 roust 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.
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Type or Print Name Title or Authority
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Signa Date
a Notary Public of the County of, ! G[7 ""Son
State of North Carolina, hereby certify that A appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Him/Her.
Witness my hand and notarial seal, this day of 20,,7,
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MARNiTA T NCRhI $
Notary Public My Commission Expires :6'
Jackson County
State of North Carolina
My Commission Expires �i .7,d 2O�