NCC233796_FRO Submitted_20231228

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on 1/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 Tiny Home Holdings,LLC-Graded Pad
2. Location of land-disturbing activity: County Macon City or Township Smithbridge
Highway/Street 10114 Georgia Road Latitude 35.0336 Longitude -83.3836
3. Approximate date land-disturbing activity will commence: Dec 18,2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.50
6. Amount of fee enclosed: $ 450.00 . The application fee of$100.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount(Example: a 1 acre-$100.00).
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 Faron Welch E-mail Address [e-mail]
Telephone Cell# 706-490-0491 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Tiny Home Holdings,LLC 423-605-2106
Name Telephone Fax Number
PO Box 80277 5959 Shallowford Road,Suite 2112
Current Mailing Address Current Street Address
Chattanooga,TN 37414 Chattanooga,TN 37421
City State Zip City State Zip
10. Deed Book No. 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
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Tiny Home Holdings,LLC jessica [e-mail]
Name E-mail Address
PO Box 80277 5959 Shallowford Road,Suite 2112
Current Mailing Address Current Street Address
Chattanooga,TN 37414 Chattanooga,TN 37421
City State Zip City State Zip
rev 103020

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:
National Registered Agents,Inc.
Name E-mail Address
160 Mine Lake Ct.Ste 200
Current Mailing Address Current Street Address
Raleigh,NC 27615
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone) 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.
Carey V.Brown ( President
Type or print name Title or Authority
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Signature ' Date
I, , 142.551 ('U .)if[A ) , a Notary Public of the County of P (:t.1YI I —on J
T�nri�.SSc?k
State of Nola-Gavel a, hereby certify that ( 't 1( 41 x B'►re.GC appeared
personally before me this day and being duly swohi acknowledged that the above form was
executed by him.
Witnes��Ci4 'I� cilddipanotarial seal, this day of NN C,\,'t 0'1 ')4%:`- , 2I
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