NCC233498_FRO Submitted_20231128

DocuSign Envelope ID:B9F27221-F98B-494C-81348-207D0411549A
0 BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(828)[e-mail] EROSION CONTROL PERMIT
xnxw.buncombecounty.org/planning
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
k. Existing I'roperth Information
PIN(Numbers): 9675-61-8800 Project Name: The Hanson-Garcia Residence
Latitude: 35.4923 Longitude: "82.4392 Amount of fee enclosed:$ 813.75
Project Location-Highway/Street 49 Thistle Lane, Fletcher, NC
Proposed Use: XSingle Family Residence o Multi-Family o Vacation Rental o Commercial/Industrial/Other o Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 1.55 acre(s)
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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: N/A Name of Applicant Todd Hanson&Laurie Garcia
Mailing Address: 2641 64th Street NW, Gig Harbor,WA 98335
Street address: 2641 64th"Street NW, Gig Harbor,WA 98335
E-mail address: 1-0td ylaIn50v1 e, .... co.
Telephone04"37 Sl%' V59 S Cell: ( 53) 4,(3 -(v 3 ys Fax:
Name of Landowner(s)of Record: odd anson& aurie arcia
Mailing Address: 2641 64th Street NW, Gig Harbor, WA 98335
Recorded in Deed Book No: 6278 _Page: 1821
D. Contact Information—North Carolina Agent(IfApplicable)
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: Brooks Engineering Associates,PA Attn: Paul Sexton
Mailing Address: 15 Arlington Street,Asheville, NC 28801
E-mail address: [e-mail]
Telephone: 828 7"1Q0,,, Cell: 828-273-9927 Fax:
Signature: Pam(. Sttfow Date: 9/11/2023
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 meme while under oath.
1 o Name: cE t 3 • (4•✓t 50 Title: Ow/1 of
Signattuure:��``�� t L Date: Of/i7/aoa3
1, et{Aar��jl C ,a Notary Public for the County of AY it e
State of tdWr r hereby certify that lindifS0A personally
appeared before me is day and under oath acknowledged that the above form was executed by him and is correct to the best of his````,,1�1111N11111U1/1111j''
knowledge and belief. �l �� 'ON 4
Witness my hand and seal,this I :::
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c., SOTAR)i N s
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My Commission Expires - 2 i 1.. .i —I� * *c
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OFFiCf' Review Fee:$ Permit No.: Check No: '� �P ti, O
USE c��ilAI.ti.7:x0
Date Paid: Received by: Date Issued: n_ SO\
The County of Buncombe does not discriminate on the basis of disability in the admission or access to,or treatment or employment illi111[f�1�1 tAlt IAAyA�
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.