NCC224112_FRO Submitted_20221214

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Asheville Area Habitat for Humanity -New Heights Subdivision -Phase 2
2. Location of land -disturbing activity: County Buncombe City or Township Lower Hominy
New Heights Drive 35.57556 82.63417
Highway/Street Latltude(decimal degrees) LongltUde(decima� degrees)
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9,57
6. Amount of fee enclosed: $ 1'000 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Paul Reeves E-mail Address [e-mail]
Phone: Office # 828-210-9373 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Asheville Area Habitat for Humanity, Inc.
Name
33 Meadow Road
Current Mailing Address
Asheville NC
City State
10. Deed Book No. 5338
Phone: Office # Mobile #
33 Meadow Road
Current Street Address
28803 Asheville NC 28803
Zip City
State
Page No. 0092 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Asheville Area Habitat for Humanity, Inc,
Company Name
33 Meadow Road
Current Mailing Address
Asheville NC 28803
[e-mail]
E-mail Address
33 Meadow Road
Current Street Address
Asheville NC 28803
City State Zip City State
Phone: Office # 828-210-9373 Mobile # [phone]
E.
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Andrew Lauren Barnett
Name of Registered Agent
33 Meadow Road
Current Mailing Address
Asheville NC 28803
City State Zip
Phone: Office # 828-210-9369
[e-mail]
E-mail Address
33 Meadow Road
Current Street Address
Asheville NC 28803
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Andrew Lauren Barnett Asheville Area Habitat for Humanity, Inc. - Executive Director
Type or print name Title or Authority
Signature Date
I, Lwf&�.UDCLA , a Notary Public of the County of L7
State of North Carolina, hereby certify that P NNe LC 94 l_Cr&o-,bC appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ��day of , 20 2Z
Seal
``1l#too,,,
NOTgR
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n' •. PUBLIC c'
oN coy

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 3 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
Name
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip
State Zip
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip