NCC233746_FRO Submitted_20231219

CAL OSe �
• FINANCIAL RESPONSIBILITY AND OWNERSHIP FORM
TEs�01
HAYWOOD COUNTY CODE OF ORDINANCES,CHAPTER 154 EROSION AND SEDIMENT CONTROL;and,
CHAPTER 158,SLOPE ORDINANCE 1a,is)a3 P-ck-
\ 7808
No person may initiate a land-disturbing activity on one-half or more acres as covered by Chapter 154 before this form and an acceptable erosion
and sedimentation control plan have been completed and approved by the Haywood County Erosion Control Program. (Please type or print,and if
question is not applicable, place N/A in the blank.). This form also addresses artificial (i.e. cut or fill) slope construction and repair as covered by
Chapter 158. No Certificate of Occupancy will be issued and no final subdivision plat approved until the Erosion Control Office has received a
completed affidavit from the person financially responsible that the project site is in compliance with the Haywood County Slope Ordinance.
SECTION A.1. Project Name: A , ,
b 1N. °LS 19; 1 •
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2. Property Identification Number or Deed Book/Page: C$(.051 C1 l L1$Co3
3.Address of land-disturbing activity: So AzetAut r 2 /U( 2-Sl ae
•
4.Starting date for land-disturbing activity: (7-l II l Z.oZ 3
5. Purpose of this activity: ❑Residential requiring a Certificate of Occupancy, DMinor Subdivision, ©Major Subdivision,
❑Commercial or Industrial requiring a Certificate of Occupancy, ❑Other: kA.)0.s4C CArYrdt. ' i7itr{.1 �� ivo ai
6. Total acreage disturbed or uncovered (including off-site borrow or waste areas): 2_ A.C.
7. Fee enclosed: $ 100 , Bond amount: $ ,Type of Security:
8. Has an erosion and sedimentation control plan been filed? WS
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9. I will notify Haywood County Erosion Control within days of when grading equipment is moved off the site. •
10. Person to contact should sediment control or slope construction issues arise during land-disturbing activity:
Name: vCuA C e-✓ Telephone Numbers: Oas •
11. Landowner of Record(List all owners):
Name(s): / �lp/JT�rds
Mailing Address: 77/ /orf. f/-- /14 e. 4 •
•
Telephone Numbers: d2 •
Fax Number: , E-mail:
12. Person or firm financially responsible for this land-disturbing activity and compliance with the Slope Ordinance:
Name:��G(ilGC��t �J �Y �o�h
Mailing Address: 1S1 S 4 Q l'` C ,/uc-
Telephone Numbers: O 2- l¢ - b 33` /�
Fax Number: ��� (aces (Q1'4 , E-mail: e--cQ. ,A e
13. My land-disturbingT operator/contractor information is:
Name: I �CrA- Co �Yc E L-'ti`c0l/�
Mailing Address: 4 S�_ Slam Rot t41'6 !c �/! 1X-Ic. 22:-115
Telephone Numbers: G OZ. -Lo (.e 5 3 •
Rev.8-24-12

Financial Responsibility and Ownership Form
(Land-Disturbing Activities) 'U ,/
Page 3 of 3 lf
j/
Initials of Financially Responsible Person
SECTION C. ARTIFICIAL SLOPE REQUIREMENTS FOR MINOR AND MAJOR SUBDIVISIONS ONLY:
1-❑Yes, ❑No 3 My development activity is a MINOR SUBDIVISION or a MAJOR SUBDIVISION. I understand that subdivision
plats will not be approved or recorded until all subdivision roads are completed and field verified for compliance
with the Slope Ordinance.
2-EYes, ❑No 4 I understand that I must provide the Erosion Control Office with Standard Proctor test data in accordance with •
§158.10(A) of the Slope Ordinance on all proposed fill soils forming artificial slopes.
3- DYes, ❑No 41 understand I must provide the Erosion Control Office with copies of the final engineering certifications that are
kik provided to the State regarding the construction and testing of public WATER and SEWER lines anytime said
utility lines are located in a fill slope. I further understand that the person financially responsible for the slope work
shall provide copies of the final engineering certifications within 30 calendar days of completion of the work.
THE FOLLOWING NOTARIZED STATEMENT MUST BE COMPLETED FOR ANY AND ALL SECTIONS OF THIS DOCUMENT.
(This form must be signed by the Financially Responsible Person, if an individual, or by his or her attorney-in-fact. If the Financially
Responsible Person is not an individual, this form must be signed by an officer, director, partner or registered agent with the
authority to execute instruments for the Financially Responsible Person.)
I agree to conduct all land-disturbing activity on the subject property in accordance with the information provided herein
and the Haywood County Code of Ordinances. I understand and acknowledge that Haywood County assumes no liability
for the design or adequacy of this plan or the work resultant from the approval of this plan, and I now and hereafter hold
harmless and indemnify Haywood County for all grading activities for which I am responsible. I have received, if
requested, a copy of the applicable Haywood County ordinances. I agree to provide corrected information should there be
any change in the information provided herein. All 1+ formation I have provided in this form of Financial Responsibility and
Ownership is true and correct to the best of my k` owledge. I understand that failure to comply with the Erosion and
Sediment Control Ordinance or the Slope Ordinance.- - result in the assessment of civil penalties.
Person Financially Responsible:
(Sig )
Q 1 /
(Print Name)
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Land Owner:
(Signature)
chi
(Print Name).
�> 1 ,�
�,(� � ,a Notaiy Public of the County of TX)AC dy th'C.—
In the State of Alovr+111-0.4;UraiVICL, , do hereby certify that!'Iei. v. Ginodsovi
e)iact. personally appeared before me this
day and acknowledged the due execution of the foregoing instrument.
Witness my hand and Official Seal this day of 19C_P_Mr( -, 20 2
KAYLYNNE R. BOSLEY Notary: ,
NOTARY PUBLIC
Buncombe County My commission expires: Cp/2.2" Z
North Carolina
My Commission Expires 06/22/2027
Rev.8-24-12