NCC243889_FRO Submitted_20241220

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HENDEas ur'7r_.
HENDERSON CUNT, r
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 blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name QUATTLEBAUM UPWARD ROAD SITE
2. Location of land disturbing activity: County HENDERSON City HENDERSONVILLE
Highway/Street UPWARD ROAD Latitude 35.297184 Longitude-82.402481
Property Identification Number(s) PIN's 9588402114, 9588500103, 9587498514
3. Approximate date land-disturbing activity will commence:August 1 , 2022
4. Purpose of development(residential,commercial, industrial, institutional, etc.):COMMERCIAL
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 15.0
6. Amount of fee enclosed: $4,700 . 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 X Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Alvin Fuller, P.E. E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Max Quattlebaum,LLC&Quattlebaum Properties F,LLC 828-674-1953
Name Telephone
636 Boxcar Street Same
Current Mailing Address Current Street Address
Hendersonville NC 28793
City State Zip City State Zip
10. Deed Book No.3799, 1178 Page No. 143, 326 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 proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Max Quattlebaum, LLC [e-mail]
Name E-mail Address
636 Boxcar Street Same
Current Mailing Address Current Street Address
Hendersonville NC 28793
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 address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(b) 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:
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 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.
Rorart Quattlebaum Owner
Typ
na �` Title or Author'
Signature Date
o ��
I, f :\c-2- , a Notary Public of the County of 1-k Q------cAC f S ._—.
State of by , hereby certify that 2- 0 `D e_-( 0 _ (p kc.u.-
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this I I day of -c" y , 20 2 2__
Notary
Seal
My commission expires ( 1 JZ© a 2_...

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date:
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent/Attorney for Quattlebaum Properties F, LLC to apply for all
permits pertaining to development and construction associated with property located at
no address assigned but more legally known at Property Identification Number(PIN)
9588500103 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
I hereby give my/our permission to Summit Engineering Group, Inc.
to submit any plans or apply
for permits required for this project. I /We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Signed by property owner (s),
Signed
Land Owner of Record (Spell out exactly as on land records)
rr
l� /14-- tp ; ,a Notary Public for the State of � ,County of
cam-I Sc' , do hereby certify that ie©ta.e-eE 0- d.+He �a w . personally appeared
before me this ( 1 day of a�f ,20)Z and acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
SEAL
My commission expires 5) i ( 0 1 2_

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date:
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent/Attorney for Max Quattlebaum, LLC to apply for all
permits pertaining to development and construction associated with property located at
no address assigned but more legally known at Property Identification Number(PIN)
9588402114 documented at the Henderson County Courthouse _
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
I hereby give my/our permission to Summit Engineering Group, Inc. to submit any plans or apply
for permits required for this project. I/We are also giving permission for any land disturbing activity to take
place on our property without our presence, but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Signed by property owner(s),
Signed
Land Owner of Record (Spell out exactly as on land records)
i ilA, �'' / �� `'�- '`�- ,a Notary Public for the State of County of
c.-( (e/�Q -) , do hereby certify that Ea e rk- cQ -----*4 LJa.M---. personally appeared
before me this I. I day of l`‘-s---7 , 20Z2,and acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
SEAL
My commission expires Ol /< ( )-o 2_1_

Permission for Agent and/or Attorney to act on behalf of Owner(s)
Date:
Henderson County Site Development
240 Second Avenue East
Hendersonville, NC 28792
Dear Henderson County Office :
As you may know, I am acting as Agent/Attorney for Max Quattlebaum, LLC to apply for all
permits pertaining to development and construction associated with property located at
758 Upward Road but more legally known at Property Identification Number(PIN)
9587498514 documented at the Henderson County Courthouse
Land Records Office located at 85 Grove Street, Hendersonville, NC 28792.
I hereby give my/our permission to Summit Engineering Group, Inc. to submit any plans or apply
for permits required for this project. I/We are also giving permission for any land disturbing activity to take
place on our property without our presence,but understand it is our ultimate responsibility if any damage is
caused during construction to this property or any other property.
Signed by property owner (s),
J i
Signed
Land Owner of Record (Spell out exactly as on land records)
I, tA`N I W ,a Notary Public for the State of ,County of
, do hereby certify that e° c4-4"I rPti—personally appeared
before me this I \ day of ! y ,20 2Z.,_and acknowledge the due
execution of the forgoing permission form. Witness my hand and official seal,
SEAL
My commission expires