NCC231260_FRO Submitted_20230428

`Oh16E`�G BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
LANK & DEVELOPME! OWNERSHIP FORM FOR AN
it (828)[e-mail]
www.buncombecounty.orglplanning EROSION CONTROL PERMIT
INSTRUCTIONS:All sections must be completed. Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
A. Existing Property Information
PIN(Numbers): 9699-95-0536 Project Name: Black Mountain Home for Children-Student Life Center
Latitude: 35.61666 Longitude: -82.37097 Amount of fee enclosed: $ 840.00
Project Location-Highway/Street: 80 Lake Eden Road
Proposed Use: ❑Single Family Residence ❑Multi-Family ❑ Vacation Rental ❑ Commercial/Industrial/Other C'Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 1.6 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: Black Mountain Home for Children Name of Applicant: Jimmy Harmon
Mailing Address: 80 Lake Eden Rd.,Black Mountain,NC 28711
Street address: 80 Lake Eden Rd.,Black Mountain,NC 28711
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
C. Landowner(s) of Record
Name of Landowner(s)of Record: Black Mountain Home for Children,Youth&Families Inc.
Mailing Address: 80 Lake Eden Rd,Black Mountain,NC 28711
Recorded in Deed Book No: 1161 Page: 0317
D. Contact Information—North Carolina Agent (IfApplirthle)
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:
Mailing Address:
E-mail address:
Telephone: 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: Jimmy Harmon Title: Program Director
Signature: Date: ®R P 92 <SIGN HERE
I, �..5 �r�q ,a Notary Public for the County of A 3/coly crQ.
State of Sk C ,hereby certify that J'+croctuk tat\ personally
appeared before mefii At i gz'4 under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge and\1 G<�
Witness my 1aland seal,this day off ,20 Z
Notary public
Bunc°�b°
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WITNESS
Dun
.`kr� My Commission Expiresee
//Ce f.25
OFFICE Reve6WIA ItA 0.`\\`` 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.