NCC241377_FRO Submitted_20240506

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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. Paschal Jack Hughes Trust
1. Project Name g
2. Location of land-disturbing activity: County Cherokee City or Township Notla Township
Highway/Street U.S. Hwy 64 W Latitude 34.0340 Longitude-84.0999
3. Approximate date land-disturbing activity will commence: October 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.4
6. Amount of fee enclosed: $ 800'00 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Marla Hincke - Trustee E-mail Address [e-mail]
Telephone [phone] Cell# 828-557-1055 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Charlene H Hughes Owner/Trustee 828-361-3991
Name Telephone Fax Number
2533 Herndersonville Rd Apt 101
Current Mailing Address Current Street Address
Arden, NC 28704
City State Zip City State Zip
10. Deed Book No. 1182/1405 Page No.502/59 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.
Marla H Hincke Owner/Trustee [e-mail]
Name E-mail Address
PO Box 555 2500 Old Murphy Rd
Current Mailing Address Current Street Address
Murphy, NC 28906 Murphy, NC 28906
City State Zip City State Zip
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:
Name E-mail Address
Current Mailing Address Current Street Address
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.
14\a‘rik )-4, R, \a
Type or print name Title or Authority
Signature Date
I, Re /2 ( jie , a Notary Public of the County of (AP.a/eee
State of North Carolina, hereby certify that Ma./a /1 Airk'e appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
rd
Witness my hand and notarial seal, this 3 day of M , 20 2V'
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Noto Notary
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'°�b/}c My commission expires
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9
•
Continued from Items 9& 10 in Part A of the Financial Responsibility/Ownership Form fior multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Marla Hughes Hincke 828-837-0127 828-557-1055
Name Phone: Office# Mobile#
PO Box 555 2500 Old Murphy Rd
Current Mailing Address Current Street Address
Murphy, NC 28906 Murphy, NC 28906
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Charles Paschal Hughes 828-337-4122
Name Phone: Office# Mobile*
3 Carolewood
Current Mailing Address Current Street Address
Horseshoe, NC 28742
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
•
Landowner 4 of Record:
Name Phone: Office* Mobile#
Current Mailing Address Current Street Address
•
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office* Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.