NCC240100_FRO Submitted_20240112

HewoEPs ;urTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM ti_ev,_�ER c urr
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 blan!:.;
Sign the original form in BLUE INK.
Part A.
1. Project Name Brickton Road Development
2. Location of land-disturbing activity: County Henderson City N/A
Highway/Street Old Hendersonville Rd. Latitude 35.409018°N Longitude 82.505865°W
Property Identification Number(s) PIN's 9652-52-3138
3. Approximate date land-disturbing activity will commence:October 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.80 AC
6. Amount of fee enclosed: $1,100 . The application fee of $300.00 per acre
lel
(rounded up to the next acre) is assessed without a ceiling amount include a$200.00 plan review tc ac
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 Ethan Young E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Brickton Industrial,LLC 828-450-3760
Name Telephone
129 Angelina Lane 129 Angelina Lane
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
10. Deed Book No. 4037 Page No. 469 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 p..cp±:,.r,.z
the name of the owner or manager may be listed as the financially responsible party.
Brickton Industrial,LLC
Name E-mail Address
129 Angelina Lane 129 Angelina Lane
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
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 add=
of the designated North Carolina Agent:
Ethan Young EthanORYSEConstruct.com
Name E-mail Address
129 Angelina Ln. 129 Angelina Ln.
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
Telephone [phone]
(b) If the Financially Responsible Party is a Partnership or other person engaging in business u;z,:c ::n
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
by me under oath (This form must be signed by the Financially Responsible Person if an ins':
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent :,.:+�
the authority to execute instruments for the Financially Responsible Person). I agree to prc:•''!c
corrected information should there be any change in the information provided herein.
Ethan Young Manager
Type or print name Title or Authority
8.4.2023
Signature Date
I, C0. h,(. . (34k.01Vh,€ a Notary Public of the County of Aim V100)
State of Nb>r441 e_ouroIVt(hereby certify that E1h a i', kl
appeared personally before me this day and being duly sworn ack owledg that the abo:ac
form was executed by him.
Witness rp had BEA0nd notarial seal, this 1-1 dayof U S'�' , 20 z3
gslon po@ FG�
F p�PfiY � tookite;
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a T e. Notary
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sa \co. My commission expires )! t, '/ Z'7-
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