NCC240238_FRO Submitted_20240126

Check if this project is ARPA-funded 111
Attach a copy of the Letter of Intent to Fund
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,including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name LAKESHORESHORE VILLAS
"If this project involves,vmencan rcescue Plan Act(ARPA)funds,list the Project Name or Project
Number(e.g., SRP-D-ARP-0121)below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
FRF0014 Project 3.10 "Recovery Starts at Home"
2. Location of land-disturbing activity: County BUNCOMBE City or Township Arden
300 HEYWOOD Shores Drive 35 4726 82 5230
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1 1/24
4. Purpose of development(residential,commercial, industrial, institutional,etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.0
6. Amount of fee enclosed: $500 . The application fee of$100.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example:8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed?Yes 0 Enclosed [i] No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ADELINE WOLFE E-mail Address [e-mail]
Phone: Office#[phone] EXT#33 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to listadditional owners):
MOUNTIAN HOUSING OPPORTUNITES, INC. [phone]
Name Phone: Office# Mobile#
64CLINGMAN AVENUE, SUITE 101 64 CLINGMAN AVENUE, SUITE 101
Current Mailing Address Current Street Address
ASHEVILLE NC 28801 ASHEVILLE NC 28801
City State Zip City State Zip
10. Deed Book No.6148 Page No.361 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)Ifthe company is a sole proprietorship orifthe landowner(s)is
an individual(s),the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
Lakeshore Villas, LLC [e-mail]
Company Name E-mail Address
64CLINGMAN AVENUE,SUITE 101 64 CLINGMAN AVENUE, SUITE 101
Current Mailing Address Current Street Address
ASHEVILLE NC 28801 ASHEVILLE NC 28801
City State Zip City State Zip
Phone: Office #[phone] Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a)Ifthe Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Blanco Tackabery& Matamoros, P.A. [e-mail]
Name of Registered Agent E-mail Address
P.O. Drawer 25008 404 N. Marshall St.
Current Mailing Address Current Street Address
Winston-Salem, NC 27114 Winston Salem, NC 27101
City State Zip City State Zip
Phone: Office#[phone] Mobile#
Deborah L. McKenney
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina,give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #
Name of Individual to Contact(if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(c) lfthe Financially Responsible Party is engaging in business underan assumed name,give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership,orothercompany not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Geofirey Barton c
Type or print name Title or Authority
8/29/23
ature Date
I, I 1 I VJ r&E o) -& 5 , a Notary Public of the County of ++ W
State of North Carolina, hereby certify that D H appeared personally
before me this day and being duly sworn acknowlegedd halt the above form was executed by him/her.
Witness my hand and notarial seal, this day o-1V I 20
• /2101--/- C ad._
``‘.ARE E N Ga/�ii
Notary
eisiRary Public —
Buncombe My commission expires 4/4 ,/226
County
My Comm. Exp.
01-26-2025

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company S Name E-mail Address
Current Mailing Address Current Street Address
State Zip City State Zip
Phone: Office# Mobile#