NCC241568_FRO Submitted_20240522

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BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
'' PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(828)[e-mail] EROSION CONTROL PERMIT
www.buncombecounty.org/planning
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): 9646-94-4038,9646-94-8624,9646-94-8404 Project Name: Carolina Day School-Phase 113
Latitude: 35.5241 Longitude: 82.5310 Amount of fee enclosed: $ 1,417.50
Project Location-Highway/Street: 1345 Hendersonville Rd
Proposed Use: ❑Single Family Residence ❑Multi-Family ❑ Vacation Rental n Commercial/Industrial/Other ❑ Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 2.70 acre(s)
B. Landowner(s) of Record*
Name of Landowner(s)of Record: Carolina Day School,Inc
Mailing Address: 1345 Hendersonville Rd,Asheville,NC 28803
Recorded in Deed Book No: 1012,4826,48261 Page: 0161,0496,0493
*Note:Attach accompanied page to list additional owners
C. 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 Applicant: Brett Fuhrman
Mailing Address: 1345 Hendersonville Rd,Asheville,NC 28803
Street address: 1345 Hendersonville Rd
Asheville NC 28803
City State Zip
E-mail address: [e-mail]
Telephone: [phone] Cell: 303-241-4840 Fax:
**Note:If the Financially Responsible Party is not the owner of the land to be disturbed,include with this form a copy(s)of the Soil
Erosion and Sedimentation Control Agent or Landowner Authorization Form signed and dated with written consent for the applicant
to submit an erosion control plan and to conduct the proposed land disturbing activities.
D. Contact Information—Financially Res.onsible Corn.an
Company(ies)who are financially responsible for the land disturbing activity(Provide a comprehensive list of all responsible parties on
accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the name(s)of the owner(s)may
be listed as the financially responsible party(ies).
Company Name: Carolina Day School,Inc
Mailing Address: 1345 Hendersonville Rd,Asheville,NC 28803
Street Address 1345 Hendersonville Rd
Asheville NC 28803
City State Zip
E-mail address: [e-mail]
Telephone: [phone] Cell: 303-241-4840 Fax:
E. Contact Information—North Carolina Agent(Registered)
If the Financially Responsible Party is a domestic company registered on the North Carolina Secretary of State business registry,please
provide information below of the Registered Agent:
Name of Registered Name:
Mailing Address:
Street Address
E-mail address:
City State Zip
Telephone: Cell: Fax:

F. Contact Information—North Carolina Agent(Non-Resident)
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 who is registered on the North Carolina Secretary of State business
registry and is duly authorized by the financially responsible person to accept and convey correspondence regarding the aforementioned
project.
Name of Agent:
Mailing Address:
Street Address
E-mail address:
Telephone: Cell: Fax:
Signature: Date:
G. 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 have 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.The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: Brett Fuhr n Title: Interim Head of School
Signature: cr Date: Y—Z.3'`20 2-Y
I, j G/�a+e l d2ffyJ S u t' ,a Notary Public for the Countyof jB vn co nab e
eft
State of /)(; hereby certify that gYL 7 �U h r/Y1 tt fl_ personally
appeared before,cne 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
Witless my hand and seal,this 2 S day of April yy _,20 2-y
Notary ,Wir:/h ✓41OYIa4
My Commission Expires /2
OFFICE Review Fee:$ Permit No.: 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 County's TDD number is(828)250-4001.
FOR OFFICE USE ONLY
Review Fee:
Permit No.:
Date Issued:
Date Paid:
Check No.:
Rec'd By:

Continued from Section B of the Financial Responsibility/Ownership Form for multiple owners.
Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone# E-mail Address
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 3 of Record:
Name Phone# E-mail Address
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 4 of Record:
Name Phone# E-mail Address
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.
Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple companies.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#