NCC232593_FRO Submitted_20230913

Financial Responsibility DEVELOPMENT SERVICES DEPARTMENT
161 SOUTH CHARLOTTE STREET
f Ownership Form ASHEVILLE•NORTH CAROLINA•28801
M-F 8:30 AM-5:00 PM
Sedimentation Pollution Control Act
INSTRUCTIONS: All sections must be completed. If not applicable enter Record Number:
N/A. Certification must be completed in the presence of a Notary Public.
A. Property Information
PIN(s):9628-33-8790,9628-33-8499,9628-43-2859,9628-44-1782,9628-43-1782Project Name: Woodland Townhomes
Project Location/Address: 100 Woodland Drive
Proposed Distrubed area (Include off site disturbance, burrow and waste areas): 4.46 acres Acres or Sq. Ft. (circle)
Proposed Development type: Single Family Residential ❑ Multi-Family ❑ Commercial ❑ Industrial/Institution
❑Other
B. Contact Information -Financially Responsible Party
7-12-2(c) of the City of Asheville Unified Development Ordinance: "Financial responsibility and ownership:A financial
responsibility and ownership statement shall be required as a part of all completed permit applications.This financial
responsibility and ownership statement shall be signed by the person financially responsible for the land disturbing
activity or his/her attorney in fact.The statement shall include the mailing and street addresses of the principal place of
business of(1) the person financially responsible, (2)the owner of the property,and (3) any registered agents. If the
applicant is not the owner of the property to be disturbed,the permit application must include the owner's affidavit
form"The undersigned state that he/she is the person financially responsible for land disturbing activity described in
the permit application listed above and acknowledge City of Asheville Stormwater, Soil Erosion and Sedimentation
Control Ordinance and that he/she has thereby been advised of the requirements therein as well as the penalties in the
event of violation of this Ordinance.
Name of Business/Person: TR 36 Woodland Drive,LLC Name of Applicant: John Boniface
Mailing Address: 6260 Avalon Blvd City: Alpharetta State:GA Zip: 30009
Street Address: 6260 Avalon Blvd Alpharetta,GA 30009 Telephone: [phone]
Email address: John@tnlogyic corn Cell:
C. Property Owner:
Name of Landowner(s) of Record: Birch Circle Associates LLC
Mailing Address: 1944 Hendersonville Road Ste El City: Asheville State:NC Zip:28803
Recorded in Deed Book No: 6106 Page:1392
6106 1408
D. Contact Information- North Carolina Agent (if Applicable)
7-12-2(c) of the City of Asheville Unified Development 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 this section."
Name of Agent: Derek Allen
Mailing Address: 20 Town Mountain Road-Suite 100 City: Asheville State: NC Zip: 28801
Email address: [e-mail] Cell: 828-412-4026 Telephone::[phone]
Signature: l 4 `J Date: �/ i `( A 3

E. Certification
I,the undersigned,attest that I am the financially responsible party or authorized representative with signatory
authority for the financially responsible party, responsible party for the construction activities and maintenance of the
site until ownership is completed for the above reference project. The above information is true and correct to the best
of my knowledge and belief and was provided by me while under oath.
Name: Derek Allen Title: Signatory
Signature: " Date: 3 `1 / 3
I, Stt/ "CSC 7 , Notary Public for County of ,3UNe-oW/d6;--
State of / V77( C {Jf , hereby certify that IO Ih 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 their
knowledge and belief. u
Witness my hand and seal, this �1
71' day, of /I,'/2G11- , 20 23
Notary:
Stuart Small My Commission Expires:
NOTARY PUBLIC
Buncombe County, NC
My Commission Expires May 23, 2027
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