NCC231223_FRO Submitted_20230426

1 SIN CoGy< JACKSON COUNTY PERMITTING& CODE ENFORCEMENT
Land Disturbance:One-Half(1/2)or more Acres/Stormwater Installation
Financial Responsibility/Ownership Form
p �.e Sylva Office:401 GrindstafCove Rd Suite 145,Phone: [phone]/Fax: [phone]
ATN CAPON` Cashiers Office: 357 Frank Allen Road,Phone: [phone]/Fax: [phone]
No person may initiate a land-disturbing activity and/or stormwater installation on more than one-half acre as covered by the
Act before this form and an acceptable erosion and sedimentation control/stormwater plan have been completed and
approved by the Jackson County Office of Permitting&Code Enforcement. If work is started without an approved permit
your permit fee will be doubled.
• Please type or print,and if any question is not applicable or the e-mail and/or fax information unavailable,
place N/A in the blank.
• Submit three(3)copies of the plan,a narrative,and the appropriate fee;please contact our office for an
accurate fee calculation before submitting paperwork. For fee calculation call 828-745-6850 or e-mail
tiffanyquallsaijacksonnc.org or [e-mail].
• A surety bond is required for any disturbance of five(5) acres or more
Part A
1. Project Name: Camp Creek Phase 1 PIN 7624-10-5375
2. Location of land-disturbing activity/stormwater installation: (City or Township) N/A
Highway/Street Camp Creek Road Latitude 35.434056 Longitude-83.294527
3. This project will require the review of the following. Erosion Control QStormwater
Is this project within a regulated district?❑✓No QYes—District Development Agreement
4. Approximate date work will begin onsite:lune 2022
5. Purpose of development(residential,commercial,industrial,etc.) Residential with some limited mixed use/commercial
6. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 16
7. Amount of fee$ FOR OFFICE USE:Received?(caudal/date)
8. Has an erosion&sedimentation control/stormwater plan been filed? I INo Yes T Enclosed
9. Person to contact should issues arise during land-disturbing activity/stormwater installation:
Name Nathaniel Crowe E-mail Address bunscrow®ebci-nsn.gov
Phone [phone] Cell Fax
10. Landowners(s) of Record (Use blank page to list additional owners) Deed Bk/Pg 22/718 (Provide a copy)
Name Eastern Band of Cherokee Indians Phone [phone] Fax
Current Mailing Address Po Box 455
Part B
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.
Eastern Band of Cherokee Indians [e-mail]
Name E-mail Address
PO Box 455
Mailing Address Street Address
Cherokee NC 28719
City State Zip Code City State Zip Code
828-359-6903
Phone Fax Number

1. (a) If the Financially Responsible Party is not a resident of North Carolina,please give name and street
address of a North Carolina Agent.
Name E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone Fax Number
(b) If the Financial 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 Financial Responsible
Party is a Corporation,give name and street address of the Registered Agent.
Name of Registered Agent E-mail Address
Mailing Address Street Address
City State Zip Code City State Zip Code
Phone Fax Number
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 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 authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any changes in the information provided herein.
Richard Sneed Principal Chief of Eastern Band of Cherokee Indians
Type or Print Name Title or Authority
Sit' ature Date
•Te-e__j 1-e.44,121-/N tary Public of the County of all()
State of North Carolina,hereby certify that K\C tv,r- 3 n t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Him/Her.
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Witness my h iisa4ppotarial seal,this day of rnifG (IS 4— ,20n�o�
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