NCC230330_FRO Submitted_20230217

4W
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 34&
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 N/A in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name'Hendersonville Road Commercial Site, Fletcher
2. Location of land -disturbing activity: County Henderson
Q
City Fletcher
Highway/Street 3122 Hendersonville Road Latitude 4;'+3` 0 Longitude ' S2 ' 6
Property Identification Number(s) PIN's 9653-63-7344
Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.71
6. Amount of fee enclosed: $ 1,700 The 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Marty Kocot, PE E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kompo Family Company, LLC
Name Telephone
J. Carr Swicegood 828-779-9020
Current Mailing Address Current Street Address
418 McDowell Street Asheville NC 28803
City State Zip City State Zip
10. Deed Book No. 3945 Page No. 618 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 firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Long Shoals Partners, LLC [e-mail]
Name E-mail Address
Carr Swicegood
Current Mailing Address Current Street Address
418 McDowell Street Asheville NC 28803
City State Zip City State Zip
Telephone [phone] 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
(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.
J. Carr Swicegood
Type or print name
Si
Lydia K. Sams
State of North Carolina
appeared personally before
form was executed by him.
Member
Title or Authority
Date
a Notary Public of the County of Madison
_, hereby certify that
me this day and being
J. Carr Swicegood
duly sworn acknowledged that the above
Witness my hand and notarial seal, this 24 day of October 12022
LYDIA K SAMS
NOTARY PUBLIC otary
Mad County o�/�171
North Carolina My commission expires 69
My Commission Expires 03/17/2026

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date: October 25, 2022
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent / Attorney for Kompo Family Company, LLC to apply for all
permits pertaining to development and construction associated with property located at
3122 Hendersonville Road, Fletcher, NC I but more legally known at Property Identification Number (PIN)
9653-63-7344 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
I hereby give my / our permission to Landworks Engineering, PLLC to submit any plans or apply
for permits required for this project. I / We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Kompo Family Company, LLC
Signed by prope
Signed
Land Owner of Record (Spell out exactly as on land records)
a Notary Public for the State of rL© %Lt 0/4 , County of
6+�V,aL 2TA do hereby certify that �2./ ersonally aDL)earered
before me this o�,i~ day of Oc'ro 202q�nd acknowledge the due
0
execution of the forgoing permission form. Witness my hand and official seal,
,arr�
*
JILLM,MERSEK
*
Commission # (;0 289$ so
ExP���FFlOaQe 0"dedi hruOud0BNottafy$erylo
S L
My commission expires

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date: October 25, 2022
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent / Attorney for Kompo Family Company, LLC to apply for all
permits pertaining to development and construction associated with property located at
3122 Hendersonville Road, Fletcher, NC but more legally known at Property Identification Number (PIN)
9653-63-7344 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
I hereby give my / our permission to Long Shoals Partners, LLC to submit any plans or apply
for permits required for this project. I / We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Kompo Family Company, LLC
Signed by property owry�-s),
Signed
Land Owner of Record (Spell out exactly as on land records)
I, (% � • OEIZSE,K , a Notary Public for the State of f 'O-A-/ 0#4 , County of
'.5emolSQnq do hereby certify that egq,,y �d rme-4A., .S personally appeared
before me this o?S
day of 00T , 20� I and acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
M.MERSEK
N
Comm1s81on # Qp 28955
�lFOF rto�`o`
Expires January 22 2023
Bonded rhru Budge,
putary Servlca
AL
My commission expi