NCC230912_FRO Submitted_20230403

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 a -mail and/or fax information unavailable, place NIA in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name The Cottages at Byron Forest
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Location of land -disturbing activity: County Henderson
Highway/Street Banner Farm Road Latitude 35.346
Property Identification Number(s) PIN's 9630801727
city Horseshoe
Longitude 52.561
Approximate date land -disturbing activity will commence: April, 3 2023
Purpose of development (residential, commercial, industrial, institutional, etc,): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.7
Amount of fee enclosed: $ 3,200 . 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 Brian Kirk E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rick Moore and Mitch Gaither
828-243-1846
Name
Telephone
103 McDowell Road
103 McDowell Road
Current Mailing Address
Current Street Address
Mills River NC 28759
Mills River NC 28759
City State Zip
City State Zip
10. Deed Book No. 3979 Page No. 162 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 proprieforship,
the name of the owner or manager may be listed as the financially responsible party.
Moore and Son Site Contractors
[e-mail]
Name
E-mail Address
103 McDowell Road
103 McDowell Road
Current Mailing Address
Current Street Address
Mills River NC 28750
Mills River NC 28759
City State Zip
City State Zip
Telephone[phone]
Pax Number

2. (a) 1f 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
(h) 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:
Rick Moore [e-mail]
Name of Registered Agent E-mail Address
103 McDowell Road 103 McDowell Road
Current Mailing Address Current Street Address
Mills River NCMills River NC 28759
City State Zip City State Zip
Telephone[phone]
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.
RICK MOORE MEMBER MRG
Type or print na e
Signature
Title or Authority
318123
Date
1 jg� A ,�1�i1���_ , a Notary Public of the County of 4,,Pdw4�
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appeared personally before me this day and being duly s orn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this
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