NCC242868_FRO Submitted_20240919

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Ownership
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Sedimentation Pollution Control Act
lNSTRV[DDNS� All sections must becompleted. If not applicable enter Record Number:
0/A. Certification must becompleted in the presence ofa Notary Public.
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P|N/s\' ��������1g Pn��� Name: �O�rV TQ�O� !
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PnJect Location/Address: 77 Hansel Ave. Ash8ViUe, NC 28816
Proposed Distrubed area(Include off site disturbance, burrow and waste areas): 2 r Sq. Ft. (cincle)
Proposed Development type: D Single Family Residential Q6 Multi-Family U [onn/nemjo/ Q /ndustrio&Insdtutinn
Ll Other
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7-12-2(c) of the City of Asheville Unified Development Ordinance: "Financial responsibility and ownership:A financial
responsibility and ownership statement shall be required as a part of all completed permit applications.This financial
responsibility and ownership statement shall be signed by the person financially responsible for the land disturbing
activity or his/her attorney in fact.The statement shall include the mailing and street addresses of the principal place of
business of(1)the person financially responsible, (2)the owner of the prol-,)erty,and (3) any registered agents. If the
applicant'is not the owner of the property to be disturbed,the permit application must include the owner's affidavit
form."The undersigned state that he/she is the person financially responsible for land disturbing activity described in
the permit application listed above and acknowledge City of Asheville Stormwater,Soil Erosion and Sedimentation
Control Ordinance and that he/she has thereby been advised of the requirements therein as well as the penalties it) the
event ofviolation of this Ordinance.
| NarneofBusine»s/Peoon: 77 Hansel LLC-Miller Lowry NarneofAp 77 Hansel LLC Miller Lowry
Mailing Address: 77 Hansel Ave. City: Asheville State: NC; Zip: 28806
Street Address: 77 Hansel Ave. Asheville NC2O808 Telephone: 770-280'8179
Email address: [e-mail] [m||:
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Name mfLan of Record: 77 Hansel LLC
Mailing Address: 77 Hansel Ave. City: Asheville State: NC Zip: 2,9806__J
Recorded in Deed Book No: 6322 Page: 1878
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7-l2-2/6nfthe City ofAsheville Unified Development 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 this section."
Name ufAgent.
Mailing Address: City: State: Zip:____
Email address: Cell: Telephone:
Date: _____

E. Certification
I, the undersigned, attest that I am the financially responsible party or authorized representative with signatory
authority for the financially responsible party, responsible party for the construction activities and maintenance of the
site until ownership is completed for the above reference project. The above information is true and correct to the best
of my knowledge and belief and was provided by me while under oath.
Name: Mille L wry Title: Member Signature: Date: v oo
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Ty 1 C)t l , Notary Public for County of Olaf I eaS{011
State of ,t U ,l C'c(r'4 (1 h fl , hereby certify that W 1 \-r I Cw f y personally appeared before
me this day and under oath acknowledged that the above form was executed by him and is correct to the best of their
knowledge and belief.
Witness my hand and seal,this -36 day, of MAPS , 20 23
Notary: 4,111g14)
My Commission Expires:Mb rai 2 7'7r,y3
TYRELL GILL
Notary Public,State of South Carolina
My Commission Expires 312712033
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