NCC222488_FRO Submitted_20220712

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
A6r
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name The Outpost
2. Location of land -disturbing activity: County Henderson City Hendersonville
Highway/Street 55 Pearl Lane Latitude 35.243030 Longitude-82.522820
Property Identification Number(s) PIN's 9546-81-7256, 9546-82-4265, 9546-92-2338
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Camp
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.0
6. Amount of fee enclosed: $ 67900.00 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
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 Mike Lovoy, PE E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Crab Creek Development, LLC [phone]
Name
213 S Church Street
Current Mailing Address
Hendersonville NC
City State
10. Deed Book No. 3744
28792
Telephone
213 S Church Street
Current Street Address
Hendersonville NC 28792
Zip City
Page No. 00165
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Crab Creek Development, LLC [e-mail]
Name E-mail Address
213 S Church Street
Current Mailing Address
Hendersonville NC
city
213 S Church Street
Current Street Address
28792 Hendersonville NC 28792
State Zip
City
State
93
Telephone [phone]
Fax Number N/A

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, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone
State Zip
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.
Dan Collins
Type or print name
Signature
Owner
Title or Authority
C-0- 22
Date
1 G ( L- t- Y Ind �A 0 R G A 14 , a Notary Public of the County of
gVAtLnAAt3t:
State of �4 C , hereby certify that � a^r 6 n 4- L r N S
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 Z d 7 N day of A P P- t t- , 20 Z 1
BILLY WMORGAN
Notary
eal NOTARY PUBLIC
BUNCOMBE COUNTY, KciMy commission expires D S � 3 � � Z � Z �