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HomeMy WebLinkAboutNCC242733_FRO Submitted_20240910 �*5oN cot, JACKSON COUNTY PERMITTING & CODE ENFORCEMENT `4i1b. Land Disturbance: One-Half(1/2) or more Acres/Stormwater Installation Financial Responsibility/Ownership Form �,� \�Q Sylva Office: 538 Scotts Creek Rd,Suite 205,Phone: 828-586-7560/Fax: 828-586-7563 941 caa°" Cashiers Office: 357 Frank Allen Road,Phone: 828-745-6850/Fax: 828-745-6867 No person may initiate a land-disturbing activity and/or stormwater installation before this form has been completed and an acceptable erosion and sedimentation control/stormwater plan has been approved by the Jackson County Office of Permitting&Code Enforcement. If work is started without an approved permit your permit fee will be doubled. • Please type or print, and if any question is not applicable place N/A in the blank. • Submit three (3)copies of the plan,a narrative, and the appropriate fee;please contact our office for an accurate fee calculation before submitting paperwork. For fee calculation call 828-745-6850 or e- mail tiffanyquallsna jacksonnc.org or jamiebaumgarnerajacksonnc.org. • A surety bond is required for any disturbance of five (5)acres or more Part A 1. Project Name: Triple C HWY 107 Site Improvements PIN 7641-75-2271 2. Location of land-disturbing activity/stormwater installation: (City or Township) Sylva Highway/Street NC Hwy 107 Latitude 35.367 Longitude -83.204 3. This project will require the review of the following: El Erosion Control ❑✓ Stormwater Is this project within a regulated district?oNo EYes—District: Town of Sylva 4. Approximate date work will begin onsite: 9/ 1/24 5. Purpose of development(residential, commercial, industrial, etc.) Commercial 6. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 3.25 7. Amount of fee $ FOR OFFICE USE: Received? (initial/date) 8. Has an erosion&sedimentation control/stormwater plan been filed?ON Yes ZEnclosed 9. Person to contact should issues arise during land-disturbing activity/stormwater installation: Name Mike Clark E-mail Address Phone 828.226.2906 Cell 828.226.2906 Fax 10. Landowners(s) of Record (Use blank page to list additional owners)Deek Bk/Pg 1744/ 109 (Provide a copy) Name Triple "c" Investment,Inc Phone 828.226.2906 Fax Current Mailing Address Part B 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. Triple "c" Investment,Inc. Name E-mail Address PO Box 38 151 Pressley Creek Mailing Address Street Address Cullowhee NC 28723 Cullowhee NC 28723 City State Zip Code City State Zip Code 828.226.2906 Phone Number Fax Number 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. 1. (a)If the Financially Responsible Party is not a resident of North Carolina,please give name and street address of a North Carolina Agent. Name E-mail Address Mailing Address Street Address City State Zip Code City State Zip Code Phone Fax Number (b) If the Financial 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 Financial Responsible Party is a Corporation,give name and street address of the Registered Agent. Name of Registered Agent E-mail Address Mailing Address Street Address City State Zip Code City State Zip Code Phone 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 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 authority to execute instruments for the Financially Responsible Person). I agree to provide corrected information should there be any changes in the information provided herein. Mike Clark President Type or Print Nameen Title or Authority 1.-11L 4...i Signature Date • I, i Oo.,(Y 15 a Notary Public of the County of O�SV�—� , State of North Carolina, hereby certify that I Vle- C\GYMappeared personally before me this day and being duly sworn acknowledged that the above form was executed by them. Witness.myhand and notarial seal,this I day of I(\R. 11,1,./j/f ,20 g . -... k . .---L9)(V2YW. V."\--6,•)\/\,--'-J Notary ? 41' - a - s -~~ My Commission Expires 1