NCC222149_FRO Submitted_20220610

FINANCIAL RESPONSIBILITY AND OWNERSHIP FORM
HAYWOOD COUNTY CODE OF ORDINANCES, CHAPTER 154 EROSION AND SEDIMENT CONTROL; and,
CHAPTER 158, SLOPE ORDINANCE
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No person may initiate a land -disturbing activity on one-half or more acres as covered by Chapter 154 before this form and an acceptable erosion
and sedimentation control plan have been completed and approved by the Haywood County Erosion Control Program. (Please type or print, and if
question is not applicable, place N/A in the blank.). This form also addresses artificial (i.e. cut or fill) slope construction and repair as covered by
Chapter 158. No Certificate of Occupancy will be issued and no final subdivision plat approved until the Erosion Control Office has received a
completed affidavit from the person financially responsible that the project site is in compliance with the Haywood County Slope Ordinance.
ECTION A.
1. Project Name: Calvary Road Baptist Church
2. Property Identification Number or Deed Book/Page: 7686-85-0590 Deed Book/Page: 946/899
3. Address of land -disturbing activity: 2701 SOLO Road, Maggie Valley, NC 28751
4. Starting date for land -disturbing activity: Estimated start date: May 23, 2022
5. Purpose of this activity: ❑Residential requiring a Certificate of Occupancy, ❑Minor Subdivision, ❑Major Subdivision,
Commercial or Industrial requiring a Certificate of Occupancy, ❑Other:
6. Total acreage disturbed or uncovered (including off -site borrow or waste areas): 1.2 Acre
7. Fee enclosed: $ 770.00 , Bond amount: $ , Type of Security:
Has an erosion and sedimentation control plan been filed? Attached
9. 1 will notify Haywood County Erosion Control within 21 days of when grading equipment is moved off the site.
10. Person to contact should sediment control or slope construction issues arise during land -disturbing activity:
Name: Christian Carswell
11. Landowner of Record (List all owners):
Name(s): Calvary Road Baptist Church
Telephone Numbers: 828-435-1122
Mailing Address: 2701 Soco Road, Maggie Valley, NC 28751
Telephone Numbers: 828-926-0506
Fax Number:
E-mail:
12. Person or firm financially responsible for this land -disturbing activity and compliance with the Slope Ordinance:
Name: Carolina Specialtie Construction, LLC
Mailing Address: PO Box 825, Hendersonville, NC 28793
Telephone Numbers: 828-697-7184 � lle
EAR" S 1..� C L.
Fax Number: 828-697-6863 E-mail: [e-mail]
13. My land -disturbing operator/contractor information is:
Name: Tennoca Construction Company
Mailing Address: PO Box 2379, Candler, NC 28715
Telephone Numbers: 828-665-8331
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 2 of 3
Initials of Financially Responsible Person_
14. My Building Contractor information is:
Name: Carolina Specialties Construction, LLC
Mailing Address: PO BOX 825, Hendersonville, NC 28793
Telephone Numbers: 828-697-7184
15. If the Financially Responsible Person is not a resident of North Carolina, give name and street address of a North
Carolina Agent:
Name:
Mailing Address:
Street Address:
Telephone Numbers:
Fax Number:
E-mail:
16. If the Financially Responsible Person is a partnership or other person engaging in business under an assumed name,
attach a copy of the certificate of assumed name. If the Financially Responsible Person is a corporation, give name
and street address of the Registered Agent.
Name:
Mailing Address:
Street Address:
Telephone Numb
Fax Number:
E-mail:
ECTION B. ARTIFICIAL SLOPE REQUIREMENTS FOR ALL PROJECTS:
1- &Yes, ❑No 4 1 understand that my project must comply with Chapter 158: Slope Ordinance of the Haywood County Code of
Ordinances before a Certificate of Occupancy can be issued.
2- Ves, ❑No 41 understand that all fill slopes must be compacted in accordance with the Standard Operating Procedure for
compaction. (You may request a copy of the Standard Operating Procedures or view them on the Erosion
// Control's webpage)
3- ❑Yes, E/No 4DoeS this project have any cut slopes steeper than 1:1 (horizontal: vertical) or fill slopes steeper than 1.5:1 (h:v)
_ [" and greater than fifteen feet (15') in vertical height? (Slope Plan is required, contact Erosion Control Office)
4-I Yes, ❑No ->Do all proposed artificial slopes meet the setback requirements in accordance with the Standard Operating
Procedures? **(The toe of a constructed fill slope and the top of a constructed cut slope cannot be within five feet
(5') of a property line.
5- ❑Yes, 69No ->Will any artificial slope be taller than 40 feet (vertical) and steeper than 1:1 (cut) or 1.5:1 (fill)? (Variance is
required, contact the Erosion Control Office)
6- Ares, []No 41 will provide stabilized ditches or other methods to prevent uncontrolled stormwater runoff from going over
artificially constructed or repaired slopes.
7- ❑Yes, 5lo ->Will an offsite borrow source be used for fill slope construction or repair? If yes, provide the location(s) of the
source (PIN, DB/PG, or address)
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 3 of 3
Initials of Financially Responsible Person_
ECTION C. ARTIFICIAL SLOPE REQUIREMENTS FOR MINOR AND MAJOR SUBDIVISIONS ONLY:
1- Dyes, N�No 4 My development activity is a MINOR SUBDIVISION or a MAJOR SUBDIVISION. I understand that subdivision
plats will not be approved or recorded until all subdivision roads are completed and field verified for compliance
with the Slope Ordinance.
2- Ves, DNo 4 1 understand that I must provide the Erosion Control Office with Standard Proctor test data in accordance with
§158.10(A) of the Slope Ordinance on all proposed fill soils forming artificial slopes.
3- Ves, ❑No 41 understand I must provide the Erosion Control Office with copies of the final engineering certifications that are
provided to the State regarding the construction and testing of public WATER and SEWER lines anytime said
utility lines are located in a fill slope. I further understand that the person financially responsible for the slope work
shall provide copies of the final engineering certifications within 30 calendar days of completion of the work.
THE FOLLOWING NOTARIZED STATEMENT MUST BE COMPLETED FOR ANY AND ALL SECTIONS OF THIS DOCUMENT.
(This form must be signed by the Financially Responsible Person, if an individual, or by his or her attorney -in -fact. If the Financially
Responsible Person is not an individual, this form must be signed by an officer, director, partner or registered agent with the
authority to execute instruments for the Financially Responsible Person.)
I agree to conduct all land -disturbing activity on the subject property in accordance with the information provided herein
and the Haywood County Code of Ordinances. I understand and acknowledge that Haywood County assumes no liability
for the design or adequacy of this plan or the work re?ultant from the approval of this plan, and I now and hereafter hold
harmless and indemnify Haywood County for all _ding activities for which I am responsible. I have received, if
requested, a copy of the applicable Haywood County o dinances. I agree to provide corrected information should there be
any change in the information provided herein. All ' f rmation I have provided in this form of Financial Responsibility and
Ownership is true and correct to the best n wledge. I understand that failure to comply with the Erosion and
Sediment Control Ordinance or the Slope divan a ay result in the assessment of civil penalties.
Person Financially Responsible: `/
v (Signature)
(Print Name)
Land Owner:
(Signature)
t- R K ,
(Print Name)
Nor{ 15 a NotaryPublic of the County of H un&rs6Y1
In the State of n U r+-- 0-0ar6Uv^-0- do hereby certify that eoy-m.l2X-
personally appeared before me this
day and acknowledged the due execution of the foregoing instrument.
Witness my hand and Official Seal this ��- day of 20 22
LC ,rJ
Notary.,. LAO l,�f�- �/ LUJVLI(i,
CYNTHIA G. NORRIS `� 13 I aoaa
i NOTARY PUBLIC My commission expires:
HENDERSON COUNTY, N.C.
Rev. A44a®mmission Expires 3 22