NCC223058_FRO Submitted_20220829

BUNCOMBE COUNTY
PLANNING & DEVELOPMENT
(8281 250430 . Planninginfo@8uncombeCounty,org
www.buncombecounty.org/planning
INSTRUCTIONS: Ali sections must be completed, Section E must be
completed in the presence of a Notary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FORAN
EROSION CONTROL PERMIT
CASE NUMBER:
PiN (Numbers): 962679416400600 Project Name: Extended Stay America
Latitude: 35.5351 Longitude:-82-6067 Amount of fee enclosed: S 980
Project Location - Highway/Street: 33 Rocky Ridge Road / Asheville, NC _
Proposed Use: O Single Family Residence o Mulii-Family ❑ Vacation Rental QCCatnnrerciol/IndrrsD�ial/Odter o Other
Proposed Disturbed Area (Include offsite borrow and waste areas): 2.45 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 or financial responsibility and ownership". This statement shall be signed by the person
Financially responsible for the land disturbing activity or his attorney in fact. The undersigned states that he/she is ilia 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 the 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 the project covered by the application.
Name of Business: TGC Asheville, LLC Name of Applicant: Nicholas J. Esterline
Mailing Address: 322 S Mosley Street / Wichita KS / 67202
Street address: 322 S. Mosley Street / Wichita, KS / 67202
E-mail address: [e-mail]
Telephone: [phone] Cell: Fax:
Name of Landowner(s) of Record: Claude Wright (c/o Linda Culbertson)
Mailing Address: 2625 New Leicester Highway / Leicester. NC / 28748
Recorded in Deed Book No: _ )144 Page: n166
D. Contact Information — North Carolina Agent (1fApl)HC;1b1V)
Section 26-228(b) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person Financially responsible
is not a resident of Nonh Carolina, a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-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: Georgina Vega of URS Agents, LLC
Mailing Address: 176 Mine Lake Court, Suite 100, Raleigh, NC 27615
E-mail address: [e-mail]
Telephone: [phone] celL Fax: [phone]
Signature: Date: 8/ 2 3/ 2 2
1, the undersigned, attc t to lire financially responsible party or an authorized representative with signatory authority for the
financially respoX
party, r ponsible for the construction activities and maintenance of the site until ownership is completed for the
above referenceect. I ark otvledg. receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and hhereby bn advised of the requirements therein as well as the penalties and resources available to ilia County in
the event of vi6a ion of the O Lance. The above information is true and correct to ilia best of my knowledge and belief and was
provided by It' under ath.
Name: Nieho . Est r n4e of TGC Asheville LLC Title: ,c.,-
Signature: Date: !g 04jir�
i
1, �7 D Pin 1 a Notary Public for the County of — v
State of S hereby certify that kI"gha personally_
appeared before tria this day and under oath acknowledged that the above form was executed by him and is correct to the best ofiis
knowledge and belief. :w
Witness my hand and seal, this r>�s, day of / Ao 20_�� _.
Notar
y My Commission Expires
AFICE Review Fee: S Permit No.: Check No:
Date Paid: Received by: Data Issued:
The County ofBinicombe dues not discriminate on the basis of disability in the admission or access to, or treatment or employment in,
its programs or activities. Reguesis jar appropriate anrilimy aids and sernices, when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services, programs, or activities, may be made by contacting
Buncombe Count}, Erosion Control, [phone]. Buncombe County's TDD number is [phone].
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MY APPOINTMENT
EXPIRES 11-5-2024
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