NCC223179_FRO Submitted_20220912

BUNCOMBE COUNTY
p PLANNING & 1)FVF_1 ODYFI,,"T
(826) 2504530•Planninglnton,BuncombeCounty.org
www.buncombecounty.orgipla nn ing
INSTRUCTIONS: All scctsonc must be completed. Section D must be
mmpleled in the presence of a rotary Public.
FINANCIAL RESPONSIBILITY/
OWNERSHIP FORM FOR A
STORMWATER PERMIT
CASE NUMBER:
Project Name; Crossroads Community Public Trail
PIN (Numbers): 9628-80-6023 : 9627-89 911 i
L.atilude: 35.56535 Longitude: -82.50671 Amount of fee enclosed: S 1-386.00
Project Location -111ghway/Street• 99999 Hominy Ridge Court; 113 Hominy Ridge Court
Proposed Use: ❑ Single Family Residence o Mull! -Family o Yccaiion Rental o Commercial/1ndu3rrlal a Other
Proposed Disturbed Area (include offshe borrowand mzste areas): 2'64 aere(s)
Name of Applicant: Crossroads Community,LLC, State of Business Registration (ifapplicable): ._
Applicanl's Point of Contact (for official cormspondencY): Andrew Klenk
Mailing Address: 1600 Camden Road, Charlotte, NC 28203
Street address: 1600 Camden Road, Charlotte, NC 28203
E-mail address: Stevie®catalystcp.gom
Telephone: [phone] Cell: Fax:
Name of Landowner(s) of Record: Crossroads Community, LLC.
Mailing Address: 1600 Camden Road, Charlotte, NC 28203
Recorded in Dad Book No: 6027 Page. 1767
Name of Landowner(s) of Record: Asheville Hominy Rlverblue, LLC.
Mailing Address: 1600 Camden Road, Charlotte, NC 28203
Recorded in Deed Book No: 6223 Page; 0225
Note: 1f applicant is not landowner of record, provide executed Buncombe County Stormwuter Agent AuthorL-otlon Form
1, the undersigned, attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party, responsible for the installation, operation, and maintenance of the stormwater controls until ownership
is conveyed for the above referenced project. 1 acknowledge receipt of a copy of the County of Buncombe Stomwater Management
Ordinance and have 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. The above information is true and correct to the best of my knowledge and belief and
was provided by me while under oath.
Financially Resp sib[e Patty. .�aCommunity, LLC, /
Sigoattue: Date: G�J �l2v� 2—
Name: L do.s/1 Title: plrector of Construction
1, jL�vtr4 CqR15TIA1JSEN a Notary Public for the Cotmtyof _*CKuwiBuz-
State of N C R-TP GRPMUr1A , hereby certify that AOA eA L. • Sort fS oersrnally
appeared before me this day and under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge and
Witness dayof390E .20 22-
�� Notary
s
O ar •.� { s My Commission Expires
tw
OFFICE" lllr6A(+ktas8""Penait No.: Check No:
USE Date Paid- Received by: Date 6sued:
7hr County of Buncomhc does not diserfminate on the basis of disability in the admission or access to, or treatment or employranent in,
ris programs or acrivirie r. Requests for approprlaie amdllary aids and services, when necessary to offer a person with a dtsvb liry an
equal upportuniry to pat7icipare in or enje v the beaefris of County services, programs, or activities, may be made by contacting
Buncombe County Erasion Control, [phone]. Buncombe Couni ,,`s rDD number is [phone].

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DFV71 r- r" "FNT OWNERSHIP FORM FOR AN
(828)25MM-Planriinglnfo&uncombeCounty.mp EROSION CONTROL PERMIT
www.bunrombecourtty.orylplannlaq
INSTRUCTIONS: All sections muss be completed. Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
PIN (:'Numbers): 96:8-80-& .1 : 96.7-39 9111 Project Nerne: Cr�wvud� Cunmunzit- Fi�n�u T�.J
Latitude: as 56535 Longitude: -117 6t1671 Amount of fee enclosed: S 1.1r6 rs,
Project Location - HighwayiStreet: 9v999 H-my RAle Cnan I I t ll—.X cad a C-rt
Proposed [fee: ❑ Single Family Retidence ❑ Multi -Family o Vacation Rental ❑ Commerviall7ndustrial/Other s(Other
Proposed Disturbed Area (Include of sere borrow and Knste areas): 264 acrt(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 of financial responsihi I ity 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 the 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 vioiation of the Ordinance, including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project cavcrcd by the application.
Name of Business: Craeu-& C. umry. LLC. Name of Applicant:. Andrew Kteak
Mailing Address; 16ea C-.kN Rn.d, tbartizie. NC 29203
Street address: 1600 Camd n Roo& Chulonc, NC 25201
E-mail address: �c�tcp.co-
Telephone IM417MA 1 Cell: Fax:
Name of Landowner(s) of Record: Cz---h Cammun . tu-
Mailing Address: 16uo carmen Kwd. Cl Awl . NC 2a2o3
Recorded in Deed Book No: bon Page: 1767
Section 26-228(h) of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "If the person financially responsible
is not a resident of North 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:
Mailing Address:
E-mail address:
Telephone: 4 Cell: Fax:
Signature: Hate:
I, the undersigned, attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party- responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project. I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised ofthc requirements therein as well as the penalties and resources available to the County in
the event ofviolalion of the Ordinance. The above information is We and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: Adun E rases Title: @recur w cuamutum
Signature: Date: AIAII;-v;-.z_
i -. z , a Notary Public for the County of, M (CX C+JDvX 6
Staleof N01L- ►} CARc+- 04 _ , hereby certify that AnRr' L— . �]Nt S _ _ personally
appeared before me this day and under oath acknowledged that the above form leas executed by him and is correct to the lest of his
knowledge and belief.
Witness my hand and seal, this day of 4 6JE . 2021,
ArMMnastrrarahy
ID CM18i Notary
�Ly' yi
"+r My Commission Expire, ?, 1o2(e
r
Permit No.: Chock No:
LrSF pate - RomvW b)r. pate Issued:
County of Buncf es nordiscriminare on the basis of disabilrry in the admission or access to, or treatment or employment in,
rP �Vel � Requests for appropriate auxiliary aids and sen7ces. K hen necessary to offer a person Kith a disability an
q �htictpare in or enjoy the bengfits of County services, programs, or activities. may be made by contacting
Ll1'Jfrt! &Usron Control. (828) 250-484A. Buncombe Counn,'s TDD number is [phone].