NCC233688_FRO Submitted_20231214

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
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
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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.)
Part A.
1. Project Name Legacy at Mills River-Phase 1
2. Location of land-disturbing activity: County Henderson City or Township Mills River
Highway/Street Jeffress Rd Latitude 35.399367 Longitude 82.542557
3. Approximate date land-disturbing activity will commence: 08/15/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 63
6. Amount of fee enclosed: $ 4095 . The application fee of$65.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Pass E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Ridge Retirement Partners,LLC 828-274-7084
Name Telephone Fax Number
70 Peachtree Road, Suite 210 70 Peachtree Road, Suite 210
Current Mailing Address Current Street Address
Asheville NC 28803 Asheville NC 28803
City State Zip City State Zip
10. Deed Book No. 3087 Page No. 448 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 proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Blue Ridge Retirement Partners,LLC
Name E-mail Address
70 Peachtree Road,Suite 210 70 Peachtree Road,Suite 210
Current Mailing Address Current Street Address
Asheville NC 28803 Asheville NC 28803
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Rick Grant [e-mail]
Name of Registered Agent E-mail Address
70 Peachtree Road,Suite 210 70 Peachtree Road,Suite 210
Current Mailing Address Current Street Address
Asheville NC 28801 Asheville NC 28801
City State Zip City State Zip
Telephone [phone] Fax Number
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 authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Rick Grant Registered Agent
Type or print n;f Title or Authori�/
Signatur- Date
e_ 676a2.9e._. , a Notary Public of the County of b u,nlcM,c9b-e_.
State of North Carolina, hereby certify that G/i4�.0 A. ("7:"FAUT----
appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand qacidnietairiiipl seal, this o2Z day of9
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