NCC242129_FRO Submitted_20240725

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
°• I'I..ANMf ,c t< Di VI i_C:>='Mi: N"l OWNERSHIP FORM FOR AN
,t (828)2504830-Planninglnio@8uncombeCounty,org EROSION CONTROL PERMIT
• www.buncom becou nty,orgfpl an ping
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER-
completed in the presence ofa Notary Public.
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A. Existing Property Information
PiN(Numbers): 969910036100000 Project Name: BEACON PHASE lA
Latitude:35 DEG.35'59"N Longitude:82 DEG.23'38"W Amount of fee enclosed:S 3,675.00
Project Location-Highway/Street:204 WHITSON AVE_
Proposed Use: u Single Family Residence n Multi-Family a Vacation Rental a Cou,nterrial/htdnsrrinf/Orlre,• gtOthff
Proposed Disturbed Area(Include n(jsite borrow and waste areas): 7.0 acre(s)
Contort 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 sitaII 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: I,�j C 4 c'.,J g'Lib p/Qw h®r.1 Name of Applicant: Casey "� k r! x c
Mailing Address: 1 v Bail,404 4l/d , Suva si s a tiC �-t 1 P t%�
Street address:5Q,1M e
E-mail address: CO f roy kiN Qv • Cd h/+
Telephone: a z..3 I-g $.S Cell: S Fax:
:C. Lanclowncr(s)of Record
j; Name of Landowner(s)of Record: BEACON BROTHERS LLC.
Mailing Address: 204 Whitson Ave.Swannanoa,NC 28778
• Recorded in Deed Book No: 5771 Page: 1806
D. Contact Information—North Carolina Agent(II'Applicable)
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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
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• and convey correspondence regarding the aforementioned project.
Name of Agent:
Mailing Address:
E-mail address:
Telephone: Cell: Fax:
Signature: Date:
I . 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 vhile under oath.
Name: Sey W&'fkt n S Title: Olio/VC.r
Signature: Date: �; 3 Q
i, //e4,114fe e i'1 Ps A ,a Notary Public for�the County/off /2G(Keel 416
State of N Lr
C ,hereby certify that aSe 6 1/�. r^v personally
iy ore me this day and under oath acknowledged that the above form executed by him and is correct to the best of his
`�� t geJylief.
• wsaati n afJd seal,this (3 day of /r'r ,20 y
' OZARY•'�.�+ Notary
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- My Commission Expires
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N�1 V i
is i UFF><P y�ee:S Permit No.: Check Pro: .
�C/��•'L.....••'••� �b*d: Received by: ,. Date Issued: •....::
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4 $ .t kwjtc mbe does not discriminate on the basis of disability in the admission or access to,or u•eatmenl or employment in,
ail/ �activilies.Requests liu appropriate auxiliary aids and services.when necessary to q(Jer a person with a disability an
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equal opportunity to participate in or enjoy the benefits of Comity services,programs, or activities, may he made by contacting
Buncombe County Erosion Control,[phone]. Buncombe Canalt':s TDD,member is(828)250-4001.
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