NCC231003_FRO Submitted_20230414

,„..'sg,: , BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PI LNINlilvr, Q nPVELOPMENT OWNERSHIP FORM FORA
fr . ► (828)[e-mail]
www.buncombecounty.orglplanning STORMWATER PERMIT
INSTRUCTIONS: All sections must be completed. Section D must be CASE NUMBER: ZPH2O21 00044
completed in the presence of a Notary Public.
A. Existing Property Information
Project Name: Belle Meadow
PIN(Numbers): 9618-92-4375, 9618-92-8457, 9618-92-8255
Latitude: 35.5698 Longitude: -82.6324 Amount of fee enclosed: $4,987.50
Project Location-Highway/Street: 37 Rathburn Place, 25 Rathburn Place, 15 Rathburn Place
Proposed Use: a Single Family Residence ❑Multi-Family ❑ Vacation Rental ❑ Commercial/Industrial ❑ Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 9•50 acre(s)
B. Applicant Contact Information
Name of Applicant: QP Rathburn, LLC State of Business Registration(if applicable): MA
Applicant's Point of Contact(for official correspondence): David Roover
Mailing Address: 430 Lexington St, 2nd Floor, Newton, MA 02466
Street address: 430 Lexington St, 2nd Floor, Newton, MA 02466
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
C. Landowner(s) of Record
Name of Landowner(s)of Record: QP Rathburn, LLC
Mailing Address: 430 Lexington St, 2nd Floor, Newton, MA 02466
Recorded in Deed Book No: 6114 Page: 1936-1941
Name of Landowner(s)of Record:
Mailing Address:
Recorded in Deed Book No: Page:
Note:If applicant is not landowner of record,provide executed Buncombe County Stormwater Agent Authorization Form
D. Certification
I,the undersigned,attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party,responsible for the installation,operation,and maintenance of the stormwater controls until ownership
is conveyed for the above referenced project.I acknowledge receipt of a copy of the County of Buncombe Stormwater Management
Ordinance and have 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.The above information is true and correct to the best of my knowledge and belief and
was provided by me while under oath.
Financially Responsi. =P ty; QP Rathburn, LLC
Signature: 4/L, Date: 6(2 2.2
Name: David Roover Title: Manager
I, /VGA V1. Pcul / ,a Notary Public for the County of 1k.//, F-t)Lt`-
State of M/K544 elfu;Z ,hereby certify that Z% , - (/E--.-- 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. q�
Witness my hand and seal,this d / day of J I�G� ,20
Notary 7 aCi 77j2?(--1'",
&, MICHELLE C. PAUL My Commission Expires V -t-ike d
Notary Public
COMMONWEALTH OF MASSACHUSETTS
My Commission Expires
June 02,2028
i
OFFICE Review Fee:$ 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 auxiliary aids and services, when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services, programs, or activities, may be made by contacting
Buncombe County Erosion Control, [phone]. Buncombe County's TDD number is(828)250-4001.

,÷,-osaE - BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
mom^ PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
1L--,-=-;, (828)[e-mail]
www.buncombecounty.orglplanning EROSION CONTROL PERMIT
INSTRUCTIONS:All sections must be completed. Section E must be CASE NUMBER: ZPH2O21-00044
completed in the presence of a Notary Public.
A. Existing Property Information
PIN(Numbers): 9618-92-4375,9618-92-8457,9618-92-8255 Project Name: Belle Meadow
Latitude: 35.5698 Longitude: -82.6324 Amount of fee enclosed: $4,987.50
Project Location-Highway/Street:37 Rathburn Place, 25 Rathburn Place, 15 Rathburn Place
Proposed Use: a Single Family Residence o Multi-Family o Vacation Rental o Commercial/Industrial/Other ❑ Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 9.50 acre(s)
B. Contact Information Financially Responsible Person
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership".This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact.The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion 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: QP Rathburn, LLC Name of Applicant:David Roover
Mailing Address: 430 Lexington St, 2nd Floor, Newton, MA 02466
Street address: 430 Lexington St, 2nd Floor, Newton, MA 02466
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
C. Landowner(s) of Record
Name of Landowner(s)of Record: QP Rathburn,LLC
Mailing Address: 430 Lexington St, 2nd Floor, Newton, MA 02466
Recorded in Deed Book No: 6114 _Page: 1936-1941
D. Contact Information North Carolina Agent (ifApplic•able)
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 of receiving 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: Jeffrey J. Owen
Mailing Address: 48 Patton Avenue
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
Signature: Date:
E. Certification
I,the undersigned, attest that I am the financially responsible party or an authorized representative with 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 of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have 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.The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: David Roover t Title: Manager
Signature: IV Date: 6/2 12 Z
I, M 1 044-01--e- Psi ,a Notary Public for the County of A oe-f-`f)C_/< ,
State of M/4-55 i10.4 I/1 ,hereby certify that 7444� 0 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.
W it�"fip 3 I H C." day of V �� ,20 �� -
* Notary Public Notary COhdMONNEALTH to MASSACHUSETTS
. ir
+ My Commission Expires
J1, June 02,2028 My Commission Expires V ud 2-
OFFICE Review Fee:$ _ 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 auxiliary aids and services, when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services, programs, or activities, may be made by contacting
Buncombe County Erosion Control, [phone]. Buncombe County's TDD number is [phone].