NCC240983_FRO Submitted_20240409

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HFtioEaso uurr FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HE,a�EasoN c9uNrr
SEDIMENTATION POLLUTION CONTROL ACT
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Providence Walk (1st Take)
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street N. Main Street Latitude 35.3371 Longitude-82.4602
Property Identification Number(s) PIN's See Attached
3. Approximate date land-disturbing activity will commence: 12/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.77 Acres
6. Amount of fee enclosed: $200 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac=$2,900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Debra Green E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
D.R. Horton Inc. 828-458-8566
Name Telephone
80 Peachtree Rd. Ste 200 8025 Arrowridge Blvd
Current Mailing Address Current Street Address
Asheville NC 28803 Charlotte NC 28273
City State Zip City State Zip
10. Deed Book No.4134 Page No.628-630 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.
D.R. Horton Inc. [e-mail]
Name E-mail Address
80 Peachtree Rd. Ste 200 8025 Arrowridge Blvd.
Current Mailing Address Current Street Address
Asheville NC 28803 Charlotte NC 28273
City State Zip City State Zip
Telephone [phone] Fax Number 855-793-2347

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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
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.
Debra Green Division President
Typ or print nail Title or Authority
04/01/2024
Signature Date
Heather Southerland a Notary Public of the County of Buncombe
North Carolina Debra Green
State of , hereby certify that
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this 1st day of pril 2024
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