HomeMy WebLinkAboutNCC224140_FRO Submitted_20221220JIt& 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 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.
I1art A. IDIZ FXL
.Proj1ect Name Rugby Site
2. Location of land -disturbing activity: County Henderson City Hendersonville
Highway/Street Rugby Rd Latitude Longitude
Property Identification Number(s) PIN'S 9651448562
3, Approximate date land -disturbing activity will commence: 6epte 9ber 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). All
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.92 AC.
$�
6. Amount of fee enclosed: $600.00 + ZooThe 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
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Pete Gray E-mail Address
Telephone
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pete Gray 8286068007—
Name
Telephone
238 Hyderview Drive
same
Current Mailing Address
Current Street Address
Hendersonville NC
same
City State
Zip City State Zip
10. Deed Book No.1229
Page No.132 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 rirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party
Pete Gray
Name Z.?a� HY�E��UI[w
r�iz E-mail Address
same
Current Mailing Address
Current Street Address
SWU& Mkt• i NC
Z81sg-n-T same
City State
Zip City State Zip
Telephone82860680M
Fax Number HA
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 State Zip
Telephone
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.
_ -1 L < < .. J' .4 ` 'V '4 to ,-__
Types print name Title or Authority
� r -
S1 na ure Date
O V-4 4 I'd- 'EA PW 10
, a Notary Public of the County of I j e r-s �`
State of L. ( , , hereby certify that S 0 Uj, 4t t e N � t C, v_�-
appeared personally before me this day and being duly sworn acknowledged th t the above
form was executed by him.
Witness my hand and notarial seal, this day of k s 24 2 Z
Notary
Seal
My commission expires _7y