NCC230774_FRO Submitted_20230324

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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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail andlor fax information unavailable, place NIA in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Rich Mountain - Phase 3
2. Location of land -disturbing activity: County Henderson city Hendersonville
Highway/Street Locust Grove Road Latitude35.390441 Longitude-82.439966
Property Identification Number(s) PIN's 9672-53-0112, 9672-32-9259, 9672,22-0858, 9672-23-1444, 9672-22-0353, 9672-21-2880
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):6'45
6. Amount of fee enclosed: $2,300 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameAndrew Baker E-mail [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ripple Falls LLC 616-402-0367
Name Telephone
69 Clark Gap Road 69 Clark Gap Road
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State zip City State Zip
10. Deed Book No. 3897 Page No.292 Provide a copy of the most current deed.
Part B. 3822 592
1. 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Ripple Falls LLC [e-mail]
Name E-mail Address
69 Clark Gap Road 69 Clark Gap Road
Current Mailing Address
Fletcher NC
City State
Telephone 6 l 6-402-0367
Current Street Address
28732 Fletcher NC
Zip City State
Fax Number
28732
Zip

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 Current Street Address
City State Zip City State Zip
Telephone
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephon
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.
Andrew Baker
Type rI ame
Signature
Manager
Title or Authority
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Dam
I, j _P_5) jr (]h- ader , a Notary Public of the County of
State of ` , hereby certify that �1'7C' CLJ,& ] Zziber
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 I day of E e_ 20
LESLIE 08ENAUER otary
t eal NOTARY PUBLIC
± NORTH CAROL INA My commission expires U r-
MADISON COUNTY