NCC242733_FRO Submitted_20240910

�*5oN cot, JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
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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: [phone]/Fax: [phone]
941 caa°" Cashiers Office: 357 Frank Allen Road,Phone: [phone]/Fax: [phone]
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 [phone] 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 [phone] 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
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Signature Date
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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.
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