NCC223083_FRO Submitted_20220901

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on 1/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development, Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 Buchanan Residence
2. Location of land -disturbing activity: County . Macon City or Township Franklin
Highway/Street�NickajackRdLatitudei 35.13321 tongitudel__-83.3188W
3. Approximate date land -disturbing activity will commence: 03/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1—
1.75
6. Amount of fee enclosed: $ 200 1. The application fee of $100.00 per acre
no .: : eca is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes NEnclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry Buchanan E-mail Address lbuchanan201 @frontler,com
Telephone Cell # I 828-342-2887JFax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Larry Buchanan 828-342-2887
Name Telephone Fax Number
59 White Oak Street 59 White Oak Street
Current Mailing Address Current Street Address
Franklin NC 28734 Franklin NC 28734
City State Zip City State Zip
10. Deed Book No R41 Page No. ` 1754 Provide a copy of the most current deed.
Part B.
1. Company(les) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) ff the company or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Larry Buchanan lbuchanan201(a),frontier.com
Name E-mail Address
59 White Oak St
Current Mailing Address
Franklin NC 28734
City State Zip
59 White Oak St.
Current Street Address
Franklin NC 28734
City State Zip

Telephone: [phone].�.-_.. T^ Fax Number
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 Fax Numbe
(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:
1
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone I Fax Number
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.
Gt rrk D
-IvDe or tint Title or Authority
Si. natur ©ate
a Notary Public of the County of m7- ;,
State of North Carolina, hereby certify that _�3 L-(, c1ar)Ci Y) ]appeared
personally before me this day and being duly s rn acknowledged that the above form was
executed by him.
Witness my ha�rtd��n°ftpl seal, this ja day of Ma —�, 20
aC;SARY
ram, Notary
My commission expires U�'�