NCC241967_FRO Submitted_20240628

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Old Fort Multifamily
2. Location of land-disturbing activity: County:_McDowell City or Township: Old Fort
Highway/Street Old Catawba River Rd Latitude(decimal degrees) 35.6236°N Longitude(decimal degrees)82.1847°W
3. Approximate date land-disturbing activity will commence: July 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.6
6. Amount of fee enclosed _$700 . The Express Permitting application fee is a dual
charge. The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which
the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is
$2,900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Stanley E-mail Address adamqaranco.com
Phone: Office# 336-368-2788 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
4BT Investments 1, LLC 828-273-9702
Name Phone: Office# Mobile#
33 Grovewood Rd 33 Grovewood Rd
Current Mailing Address Current Street Address
Asheveille NC 28804 Asheville NC 28804
City State Zip City State Zip
10. Deed Book No. 1377 Page No._584 Provide a copy of the most current deed.

Part B.
1. 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).
4BT Investments 1, LLC grantbaird(a�gmail.com
Company Name E-mail Address
33 Grovewood Rd 33 Grovewood Rd
Current Mailing Address Current Street Address
Asheville NC 28804 Asheville NC 28804
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office# Mobile #
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name
under which the company is Doing Business As If the Financially Responsible Party is an individual,
General Partnership, or other company not registered and doing business under an assumed name,
attach a copy of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
LPK Consulting, PA JLipka(o�LPK-Consultinq.com
Engineering firm or other consultant E-mail Address
John Lipka 336-945-0302 704-936-7406
Individual contact person (type or print) Phone: Office # Mobile #
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(s) 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 Party). I
agree to provide corrected information should there be any change in the information provided
herein.
Grant Baird , jVlanaging Member
Type or print name Title or Authority
/ 1 q
Date
I, y4.1e�, , a Notary Public of the County of �cfu�vx�c_
State of North Carolina, hereby certify that bra lit e.. r,"( appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her.
Witness my hand and notarial seal, this / g day of , 20
Timothy J. Peace
Notary Public
Buncombe County, NC
My Coamiaa ExpirM 11 r1 L/a 5
:yea, My commission expiresf/ it/avesJ4->/ 2O

9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ben Pruett 828-699-3829 828-699-3829
Name Phone: Office# Mobile#
247 Old Catawba River Road 247 Old Catawba River Road
Current Mailing Address Current Street Address
Old Fort NC 28672 Old Fort NC 28672
City State Zip City State Zip