NCC233717_FRO Submitted_20231215

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& /<< Financial Responsibility- DEVELOPMENT SERVICES DEPARTMENT
U m 161 SOUTH CHARLOTTE STREET
z Q Ownership Form ASHEVILLE• NORTH CAROLINA•28801
�Pr o�� M-F 8:30 AM-5:00 PM
CA
R Sedimentation Pollution Control Act
INSTRUCTIONS: All sections must be completed. If not applicable enter Record Number:
N/A. Certification must be completed in the presence of a Notary Public.
A. Property Information
PIN(s): 9654-40-6526 Project Name: Los Amigos Site Demo
Project Location/Address: 2506 Hendersonville Road Arden, NC 28704
Proposed Distrubed area (Include off site disturbance, burrow and waste areas): 0.81 432 or Sq. Ft. (circle)
Proposed Development type: ❑ Single Family Residential ❑ Multi-Family ICI Commercial ❑ Industrial/Institution
❑Other
B. Contact Information - Financially Responsible Party
7-12-2(c) of the City of Asheville Unified Development Ordinance: "Financial responsibility and ownership:A financial
responsibility and ownership statement shall be required as a part of all completed permit applications.This financial
responsibility and ownership statement shall be signed by the person financially responsible for the land disturbing
activity or his/her attorney in fact.The statement shall include the mailing and street addresses of the principal place of
business of(1)the person financially responsible, (2)the owner of the property,and (3) any registered agents. If the
applicant is not the owner of the property to be disturbed,the permit application must include the owner's affidavit
form."The undersigned state that he/she is the person financially responsible for land disturbing activity described in
the permit application listed above and acknowledge City of Asheville Stormwater,Soil Erosion and Sedimentation
Control Ordinance and that he/she has thereby been advised of the requirements therein as well as the penalties in the
event of violation of this Ordinance.
Name of Business/Person: MH Mission Hospital, LLLP Name of Applicant: ATTN: Chief Financial Officer
Mailing Address: 509 Biltmore Avenue City: Asheville State: NC Zip: 28801
Street Address: 509 Biltmore Avenue Asheville, NC 28801 Telephone: [phone]
Email address: Cell:
C. Property Owner:
Name of Landowner(s) of Record: MH Mission Hospital, LLLP
Mailing Address: 509 Biltmore Avenue City: Asheville State: NC Zip: 28801
Recorded in Deed Book No: 6276 Page: 747
D. Contact Information- North Carolina Agent(if Applicable)
7-12-2(c)of the City of Asheville Unified Development Ordinance: "If the person financially responsible is not a resident
of North Carolina, a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with this section."
Name of Agent:
Mailing Address: City: State: Zip:
Email address: Cell: Telephone:
Signature: Date:

E. Certification
I,the undersigned, attest that I am the financially responsible party or authorized representative with signatory
authority for the financially responsible party, responsible party for the construction activities and maintenance of the
site until ownership is completed for the above reference project. The above information is true and correct to the best
of my knowledge and belief and was provided by me while under oath.
Name: ka Ur,e, Ha yne J Title: CG,ieF/=,;'GK;4, --
Signature: 4 / Date: 7-$f-2oZJ
I, 141-fry Val R l 6 N-( , Notary Public for County of AA e-1-
State of .k\vbf\-1-(/- p t t vl-c— , hereby certify that (-fir I nes personally appeared before
me this day and under oath acknowledged that the above form was executed by ' nd is correct to the best of their
knowledge and belief. j /� y�,er-
Witness my hand and seal,this t.S day, of AlA 3uS , 20 23
\\\\\\P• I IW R�04, Notary: -K
? Notary Public My Commission Expires: 7-2C-202"Z
McDowell
County
My Comm. Exp.
07-25-2027 Q z.
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