NCC221800_FRO Submitted_20220511

A16_r
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 N/A in the blank.)
Part A.
1. Project Name Dig Hills at Horse Shoe
2. Location of land -disturbing activity: County Henderson City or Township Horse Shoe
Address of Project. Adjcent to 2771 Brannon Roast Latitude 35.3455 Longitude 82.6016
3. Approximate date land -disturbing activity will commence. September 1, 2021
4. Purpose of development (residential; commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17.42 Ac.
6. Amount of. fee enclosed: $ 5400 Fee Schedule FY 2018-2019 is available on
Water Resourcesatlink https.,Iiwww.hendorsoncountync.govlwaterresourcestpageifee-
scheddle-fy201,9
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 Art Bayiuk E-mail Address [e-mail]
120 Dogwood Road Same.
Current Mailing Address Current Street Address
Candler NC 28715
City State Zip City. State Zip
Telephone Cell # 828.242.1879
9. Landowner(s� of Record (attach accompanied page to list additional owners) NOTE: Must snatch
Henderson County Courthouse - Land records Information or provide a recorded deed:
Big Hills'Construction, LLC 828,242,1879
Name Telephone Fax Number
120 Dogwood Road Same
Current Mailing Address Current Street Address
Candler NC 28715
City State .Zip City State Zip
City of Hendersonville FRO,doc Revised 6-1.9-2018.

10. Deed Book No, 3584 Page No. 348 Provide a copy of the most current deed.
Part B.
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) NOTE: The signature of a
corporation, or LLC must be a listed member on the formation documents on file with the
state office at httm://www.sosnc.gov/s arch/index/car
Big Hills Construction, LLC Peter Radchishin
Name
1.20 Dogwood Road
Current Mailing Address
Candler NC 28715
City State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
City
State
Zip
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 assured name, attach a copy of the Certificate of Assumed Name. If the Financially
Responsible Party's a Corporation, give name and street address ofi the; Registered Agent:
Rare
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 6-1.9-2018

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). l agree to provide
corrected informatio ould t ere be any change in the information provided herein.
Peter Radchis n
Type or print n me
Signature
Member
Title or Authority
�0 // ,� --
Date
{, 0420 ll N Y T , a Notary Public of the County .of
State of North Carolina, hereby certify that Pe.Lr /2acle-lvi-s%j appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this. 1 � day of a �� , 20 �
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�` "• Notary
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My commission expires
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City of Hendersonville FRO.doc Revised 6-1 9-2018