NCC240298_FRO Submitted_20240202

u��� liii ��;- Financial Responsibility- DEVELOP ENT S
OTCESDEPET
ARTMENT
Ownership Form ASHEVILLE•NORTH CAROLINA•28801
1 M-F 8:30 AM-5:00 PM
Sedimentation Pollution Control Act _
INSTRUCTIONS: All sections must be completed. If not applicable enter Record Number
N/A.Certification must be completed in the presence of a Notary Public.
A. Property Information
PIN(s):9629-244-778&9629-245-513 Project Name: Terminix
Project Location/Address: 351 Old County Home Road
Proposed Distrubed area(Include off site disturbance, burrow and waste areas): 1.30 Acres Acres or Sq. Ft. (circle
Proposed Development type: ❑ Single Family Residential ❑ Multi-Family ®Commercial❑ industrial/institution
❑Other
B. Contact Information-Financially Responsible Party
7-12-2(c)of the City of Asheville Unified Development Ordinance: "Financial responsibility and ownership:A financial
responsibility and ownership statement shall be required as a part of all completed permit applications.This financial
responsibility and ownership statement shall be signed by the person financially responsible for the land disturbing
activity or his/her attorney in fact.The statement shall include the mailing and street addresses of the principal place of
business of(1)the person financially responsible,(2)the owner of the property,and (3)any registered agents. If the
applicant is not the owner of the property to be disturbed,the permit application must include the owner's affidavit
form."The undersigned state that he/she is the person financially responsible for land disturbing activity described in
the permit application listed above and acknowledge City of Asheville Stormwater,Soil Erosion and Sedimentation
Control Ordinance and that he/she has thereby been advised of the requirements therein as well as the penalties in the
event of violation of this Ordinance.
Name of Business/Person: Terminix Service Inc. Name of Applicant: Mike Hoffman
Mailing Address: PO Box 2627 City:Columbia State: SC Zip: 29202
Street Address: 3618 Fernandina Road Telephone: [phone]
Email address: mhoffmantwtrustterminix.com _ Cell: [phone]
C. Property Owner:
Name of Landowner(s)of Record: Terminix Service,Inc.
Mailing Address: PO Box 2627 City: Columbia _ State:SC Zip:29202
Recorded in Deed Book No: 5393 Page: 1088
D. Contact Information- North Carolina Agent(if Applicable)
7-12-2(c)of the City of Asheville Unified Development 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 this section."
Name of Agent:Zach Gaines
Mailing Address: 105-A Center Lane City: Huntersville State: NC Zip: 28078
Email address:zgai s rustterminix.com Cell:864-934-1461 Telephone::[phone]
Signature: Date: I,'./ I a3

E. Certification _
I,the undersigned,attest that I am the financially responsible party or authorized representative with signatory
authority for the financially responsible party, responsible party for the construction activities and maintenance of the
site until ownership is completed for the above reference project. The above information is true and correct to the best
of my knowledge and belief and was provided by me while under oath.
Name:Mike Hoffman Title:Construction Manager
Signature: .% a� ,_--- Date: 12-8-2023
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I, Eli 5 � 414-17.-•o4.v, , Notary Public for County of 1,,.� ,,�,,,�-1�o_r
State of Sow C�,I;it hereby certify that LL \ personally appeared before
me this day and under oath acknowledged that the above form was executed by him and is correct to the best of their
knowledge and belief.
Witness my hand and seal,this (611 day,of 1 c,t r,-,0�r ,20 23
Notary- ift.... —
My Commission Expires:.
My Commission Expfres August 4,2020
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