NCC233120_FRO Submitted (2)_20231019

►* '_'r FINANCIAL RESPONSIBILITY/OWNERSHIP FORM ►E r
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 and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name The Cedars Lodge & Spa
1Location of land-disturbing activity County Henderson cry Hendersonville
Highway/Street 7th Avenue W Latitude 82.4629 Longitude 35.3193
Property Identification Number(s) PIN's See Attached
3. Approximate date land-disturbing activity will commence. August 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc )
Residential/Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.77
6. Amount of fee enclosed. $ 1 ,4p9 The application fee of S300.00 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 = 82,900 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 anse dunng land-disturbing activity
Name Gregg Covn E-mail Address greggcovinl@gmail corn
Telephone [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners):
See attached
Name Telephone
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No See attached Page No. Provide a copy of the most current deed
Part B.
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 or firm is a sole propnetorshrp,
the name of the owner or manager may be listed es the financially responsible party.
See attached
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number

2 (a) If the Flnenctalty Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent
N/A
Name Email Address
Current Melling 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 Financialty Responsible
Party is a Corporation, give name and street address of the Registered Agent
See attached
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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 authonty to execute instruments for the Financially Responsible Person) I agree to provide
corrected information should there be any change in the information provided herein
Gregg Covin Manager
Type or pnnt n me Title or Authonty
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Signature
Date
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, a Notary Public of the County of��, � - ,
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State ofo ACL., , hereby certify that Gly-c.,V+ C �/
appearedpersonally before me this day and being duly sw. rr` acknowledged that the above
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form was executed by him
Witness my hand and notarial seal, this aS day of_ Z\ , 20_ 2_
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