NCC242488_FRO Submitted_20240829

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM `J '
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 NIA in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Park Residences at Highland Lake Village
2. Location of land-disturbing activity: County Henderson city Village of Flat Rock
Highway/Street Highland Lake Drive Latitude 35.284202 N Longitude 82.431840 E
asneee162.a577851a1 a,aarrm,o83,e5r650141.R5 75591 27 957 5E523a.9577568269.95775S7394.9577662132
Property Identification Number(s) PIN's
3. Approximate date land-disturbing activity will commence:6/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5_ Total acreage disturbed or uncovered(including off-site borrow and waste areas):2.5
6. Amount of fee enclosed: $1100.00 . The application fee of S300.00 per acre
- (rounded up to the next acre)is assessed without a ceiling amount include a S200.00 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Steve Collins E-mail Address steve©highlandlake.net
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Highland Lake Inc. 828-239-2595
Name Telephone
11 GA Waterlily Drive 116A Waterlily Drive
Current Mailing Address Current Street Address
Flat Rock NC 2s731 Flat Rock NC 28731
City State Zip City State Zip
10. Deed Book No. Multiple Page No.SEE ATTACHED 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 maybe fisted as the financially responsible party.
Real Places Inc. [e-mail]
Name E-mail Address
1 1 6A Waterlily Drive 116A Waterlily Drive
Current Mailing Address Current Street Address
Flat Rock NC 28731 Fiat Rock NC 28731
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
(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:
` ✓ 1.15.E f>J*-"1 \ -042%1_& t \k.J 1Sf (Ly.,
Name of Regl tered Agent E-mail Address
l , , - - t 9 '.- t))k.L1•-•\ DN.
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 5 .1 (S
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.
Car-Cn.J j [M-W A<-`-)l
Type or print name----", or Authority
— 2L. - 3
Signature Date
•
, `: �-Sr� i A":!�V_# , a Notary Public of the County of4.11-4.-12/V--)
State of ' LE=;- ;il C J� 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 men day ofD.' ! , 20 a 3
CAROL RICHARD A
NOTARY PUBLIC
Henderson County Notary
Carolina nny Commission pares June 16,2027 My commission expires //
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