NCC217141_FRO Submitted_20211228

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM PORAN
(828)[e-mail] EROSION CONTROL PERMIT
www,buncombecounty.org/planning
INSTRUCTIONS; All sections must be completed, Section E must be CASE NUMBER;
completed in the presence of a Notary Public.
PIN (Pluntbers)r r e Project Nnme; %-40 /AR5
Latitude: g0 �t'IG�� Longitude: / Z �'t}8�� Amount of fee enclosed; $
Project Location -,,Highway/Slreeh 908 M�tlNiJltn/.SG'FiN�e ff Ash
✓i�E��G td
Proposed Use: gd'ligle Family Residence ❑ Afniti-Family ❑ Vacation Rental o Canntercial/Lrdaslrlal/Olher ❑ 011ie"
Proposed Disturbed Aren (Include offslte borrow and waste areas): / 'ZZ acre(s)
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance; "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership". This statement shall be signed by the person
financially responsible for lire land disturbing activity or his attorney lit fact. The undersigned states that lie/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as tine penalties and resources available to the County in the event of violation of the Ordinance, including revocation of the Land
Disturbing Permit and all building permits issued in connection with fire project coveredytile epp:lio�nYLE
Name of Business: Name of Applicant:
Mailing Address: �Tw yt�JLi77� A VEmwf u~sr- 349
Street address; .._
E-mail address; I
Cell: S.�,M E Fax:
Name of Landowner(s) of Record: %4#R rIEr—'P 1+ F "r
Mailing Address: It SDkY'N ayFAt
Recorded in Deed Book No: Ooal Page: -_"A
_ ..rs
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person financially responsible
is not a resident of North Carolina, a North Carolina agent must be designated in die statement for the purpose of receiving notice of
compliance or notr-compliance with the plan, the Act, this ordinance, or rules or orders adopted or issued pursuant to this ordinance,"
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project,
Name of Agent: _
Mailing Address:
&nail address:
Telephone: Fax:
Date:
Signature:
I, the undersigned, attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible panty, responsible for the construction activities and maintenance of the site wail ownership is completed for the
ipt of a copy of tine County of Buncombe Soil Erosion and Sedimentation Control
above referenced project: I acknowledge rece
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County in
the event of violation of the Ordinance, The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath, R�C�v
Title;Lt1A10+>Wt%trllllR d�
Name: Date:
Signature: rn b .�
I t?jl L r a Notary Public for the County of w11 t
I that_personally
State of ry Cl ( 1 LA C Ck l-U ( kk Cam- hereby certify I �1N
appeared before me this day and under oath acknowledged that the above form was execute by him and is correct to the best of his
knowledge and belief, a r
d
Witness my band and seal, this V I y of
Notary -7 `
My ConntUSaion Ex�
PenultNo.:
UGA rDetePud.• Received by; _ --
Tile Colin y of Buncombe does not discrintbrale on the basis of dlsabi/ity In the admission or access to or treatment or employment in,
lis programs or activities. Requests for appropriate auxillmv aids and services, when necessmy to offer a person with a disability an
equal Bta combeoCounly ErosioncCaleol' [phone]. Buncombe combeoCool tty's TDD number rrIs (828) 250-400Ltay be made by cotttacring