NCC240475_FRO Submitted_20240220

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
»r (828)[e-mail] EROSION CONTROL PERMIT
www.buncombecountyorglplanning
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
A. Existing Property Information
PIN(Numbers): 9796-33-1298 Project Name: 7 MOUNTAIN
Latitude:35.794757 Longitude: -82.402826 Amount of fee enclosed:$ 8400
Project Location-Highway/Street:BURLESON BRANCH ROAD
Proposed Use: xSingle Family Residence o Multi-Family o Vacation Rental o CommerciaUlndustrial/Other ❑Other
Proposed Disturbed Area(Include o/J.'site borrow and waste areas): 16 acre(s)
B. Contact Information—Financially Responsible Person
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership".This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact.The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as the penalties and resources available to the County in the event of violation of the Ordinance,including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: 7 MOUNTAIN ESTATE,LLC Name of Applicant: DOMINIK GOERTZ
Mailing Address:2256 First Street,Fort Myers,Fl 33901
Street address: 2256 First Street.Fort Myers.FL 33901
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
C. Landowner(s)of Record
Name of Landowner(s)of Record: 7 MOUNTAIN ESTATE,LLC
Mailing Address: 2256 First Street,Fort Myers,FL 33901
Recorded in Deed Book No: 6196 Page: 904
D. Contact Information—North Carolina Agent(IfApplicable)
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control 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 the plan,the Act,this ordinance,or rules or orders adopted or issued pursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent: CIVIL DESIGN CONCEPTS,PA
Mailing Address:168 PATTON AVENUE ASHEVILLE,NC 28801
E-mail address: GI-If F [e-mail]
Telephone: 8 '2, '`-8 Cell: Fax:
Signature: _,""iiii Date: .-5"Z
E. Certification
I,the undersigned,attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party,responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project.I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and hay- • reby been advised ofthe requirements therein as well as the penalties a esources available to the County in
the event of violat t„�.► u e Ordinance. r e abgy forma on is true and correct to the best knowled and be' f and was
provided by me w ;er oaA'i ' (/,/1®� c t e s
Name: fWY Title: t C/0 "
r` �� Date: 12
Signature: i O
I, iiL jib.. S ,a Notary Public for the County of
State of F'L_45 1J ,hereby certify that IYl i in t l�Gam. 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 his
knowledge and belief.
i,t-s• -hand and seal,this day of _ ,20 D- 3
�
Julie A. Myers � Notary �
NOTARY PUBLIC-STATE OF FLORIDA
MY COMMISSION EXPIRES JUNE 14,2027 is' My Commission Expires
COMMISSION NO.IIH 377997
�firii _,_,�^^✓�:`. �r_i_�._s_ PennitNo.: Check No:
USE Date Paid: Received by: Date Issued:
The County of Buncombe does not discriminate on the basis of disability in the admission or access to,or treatment or employment in,
its programs or activities.Requests for appropriate auxiliary aids and services, when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services,programs, or activities, may be made by contacting
Buncombe County Erosion Control,[phone]. Buncombe Countvs TDD number is(828)250-4001.