NCC233710_FRO Submitted_20231215

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Brevard Staytion
2. Location of land-disturbing activity: County Transylvania City or Township Brevard
Asheville Hwy Highway/Street Y Latitude(deci 35.263764 ma,degrees) Li 82.715565
ong tude(decimai degrees)
3. Approximate date land-disturbing activity will commence: October 15, 2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.):Commericial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.95
6. Amount of fee enclosed $1400 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre(rounded up to the next acre)is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Josh Shober E-mail [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Pisgah Hospitality, LLC
Name Phone: Office# Mobile#
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
10. Deed Book No. 1 050 Page No. 1 51 -153 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Pisgah Hospitality, LLC [e-mail]
Company Name E-mail Address
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office#800-927-9800 Mobile#
Yvette Bronner
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership,or other company not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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consultant who can assist in providing any necessary information regarding the plan and its preparation:
High Country Engineering, PC rncayabyab© hcepc.net
Engineering firm or other consultant E-mail Address
Marie Cayabyab [phone] [phone]
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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(s)
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 Party). I agree to provide
corrected information shoilrl there hp any change in the information provided herein-
Brice J. Bay Member
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I, 145 n b-S cc l T , a Notary Public of the County of CIt(2¢ntA l
State oksVCarolina, hereby certify that 51(ICC. • appeared person Ily
before me this day and being duly sworn wasacknowledged that the a ve form�� executed by nlmih r.
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Witness my hand and notarial seal,this day 20
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