NCC220953_FRO Submitted_20220307

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name FERNLEAF COMMUNITY CHARTER SCHOOL
2. Location of land -disturbing activity: County HENDERSON City Or Township
NIA
Address of Project: Latitude Longitude
OLD HENDERSONVILLE RD 35.404164-82.505892
3. Approximate date land -disturbing activity will commence: JAN 31, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): EDUCATIONAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $ 3,600 . Fee Schedule FY 2018-2019 is available on
Water Resources at link https://www.hendersoncountync.gov/waterresources/page/fee-
schedule-fy2019
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Cell #
9. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must match
Henderson County Courthouse - Land records information or provide a recorded deed:
FERNLEAF HOLDINGS, LLC [phone]
Name Telephone Fax Number
58 HOWARD GAP RD
Current Mailing Address Current Street Address
FLETCHER NC 28732
City State Zip City State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

10. Deed Book No. 003453 Page No. 00280 Provide a copy of the most current deed.
Part B.
1. Person(s) or firms who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) f; 0T'E;: i :_ entur•e of a
.":r:.LC a't;ust 6,e c'a iiaL!d ;: em"131• a rmorr�-,,'!','.n doc3.i_-._wont'-. C'n We 11! tl++)
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MICHAEL S. LUPLOW [e-mail]
Name E-mail Address
58 HOWARD GAP RD
Current Mailing Address Current Street Address
FLETCHER NC 28732
City State Zip City State Zip
Telephone [phone]
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(b) If the Financially Responsible Party is a Partnership or other person engaging in business
under an assumed name, , �:owv of lb_ , 1'r Few:; r.*,- `r�,ra--- If the Financially
Responsible Party's a Corporation, give name and street address of the Registered Agent:
/
i �Rs!2
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
City of Hendersonville FRO.doc Revised 6-19-2018

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 the 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
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
MICHAEL S. LUPLOW EXECUTIVE DIRECTOR
Type or print nagrue Title or Authority
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Signatur Da
I, �C ZL , a Notary Public of the County of CO C
State of North Carolina, hereby certify that 1 C 6 hEL S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 4
Witness my hand and notarial seal, this aM . day of o0s.oAkIEr , 20 Z
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My commission expires
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City of Hendersonville FRO.doc Revised 6-19-2018