NCC215994_FRO Submitted_20211028

BUNCOMBE COUNTY
PLANNING & DEVELOF"- --1A T
_(M)2504M•[e-mail]
wwtaJxmomhecou nty.orglplan n Ing
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM 1-oRAN
EROSION CONTROL PERMIT
INSTRUCTIONS: All sections mull he completed Section E must be CA%F NUMIBE W
completed in the presence of a Notary Public
M Fn onto in
P1N (Numbers), 9678-09-9136 Project Name- _liererherid Care Strbdtvisir>� —
lsrtitndr: 35-5943 L ooXitude, 42.4641 Amount of fee encicised: 5 2524.OD
ProjectLocation-IIIghway/Strect: 55J.JI i§RoaC-----
Proposed Ilse: is Single F'amtk Rrsrdierser n Afahr-I amrlt n 1'arutrnn Rental a CommerradIndustr+alYNher n Other
Proposed Disturbed Area (lr[dade offirte borrow and wrier areas): 4.8 -acre(s)
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control C7rdinsti ae "Erosion conttol plans shall be
accompanied by a notarized statement of financial responsibility and axaerahip` This statement shall be signed by the person
financially respanssblc for the laird disturbing activity or his attorney in fat The undersrgnad states that helshe is the person
financsal ly responsible fir land disturbing activity described in this appiication and acknowledges receipt of a copy of the County of
Buncombe Soil Lrosion and Sedimentation Control Ordinancc and that helshe has thereby been advised of Lire requirements therein as
vxll as the penalties and resources available to the County m the event of violanon of the Ord urati ce, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the appticabon
Name of Husisress: MouriteYi•Und i ['.a1LIB Comaart>r� LLC Name of Applicam _ SCBf! Poly ._.. —
Mailing Address:. jQ FbyeAg iarkw9AShvd* NC iM
street address.
E-mail address --
Telephone _92 9-299-35 5 3 Ceti: Fox
Name of l.ando%kncr(s) of Rcrord j iritain Land E Cltitle-CampApy, � _ _
Mailing Address w Parkway, AVievale, NC 28W5
Recorded in Ehcal llook No 4193 E':LV,c 419
See Iion 26.228(h) of the IIUncorribe County Satl limsion and Sedimentation Control Ordinance; `If the person financially responsible
is not a resident of North Carolina, a North Carolina agem must tx- designated in the statement for the fxirpose of rcceiving notice of
comptiance or non-compliance %ith the plan, the Act• this ordinance, or rules at orders adopted of issued pursuant to this ordinance
The perwn noted below is the dssignatcd North Carolina agent and is duly authorized by the financially rc"mihic person to accept
and convey correspondcnc:e regarding the a lbrerricntioncd project
Nam of Agcnt
Mailing Address
E-mail address.
Telepbotu, Cell _ Fax _
Sit rsaIu�� Date,
1• the un dersigncd• at that E arts the lnancially responsible party at an outhurircd repro%vativc with signatory authority for the
linancinll} tesponsih1v party, responsible for the construction activities and nminicnance of the site out iI ownership is completed far the
tiNn c referenced project 1 acknuo ledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have therch5 bcxn adv iscd of the rcyuircments therein as AelI as the penaloes and resources availahic to the County to
the event of violation of the 0rdinancc The above information is tnro and correct to the best of my kno%Wgc and hi:lief and %w
provided by me while underoath
Name: 5-40 ]T SroTills- 4!ry--1
Signature ^ Date
1 a Notai,, Public riir the County of
State of hereby certify that—__r,-.f� -� ��c II _ _ sortali
appeared before me this day and under oath acknowlcdgixl that dw ahove form xis executed by him and is correct to the best of his
knowledge and bellcf
W rtmcss my hand and seal. this f 1 tsi day of - - Lu4 .20- f
Susannah L. Haskell Notary
Notary Public
Buncombe County. NC My Commission E:xpires--po�
fNIF•NI" Rerim FM S_ Prnni! tier._ Chock tin•
USE Mae Paid: Reuel vad by: _— rMe issued'
the [:ounrt M Brwrcodrvhe rkxs nrN dierrimrruxr un the f+eiru ref drsuhilnrt err rh. arLnrissiwi w tree,,► rr+, ur rnrarmrnt or rnrpilm Oren, in
era prograar.s or aetnrttrs. Rryursts fr+r upproprtatr vat hart urrfs and servrtrs. „hers neressary to q(%► a lwrsan with a drsahiltn• an
eyuaf oPportuntry to prtrtnrtpase In ar enjoy the hem f is of Counry services. prugratns, or activities, may he made br conrrtrrirrk
Sartcuntbr C urmrt Frnsron C'[xrrrpl, {R?R) ?SQ-�RJ7f lluncnrrrhr t ounty x Till) number ct (X2N) 130- W1.