NCC250098_FRO Submitted_20250115

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM >�F
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 Masterpiece
2. Location of land-disturbing activity: County Henderson City Etowah
Highway/Street Pleasant Grove Road Latitude 35.293191 Longitude-82.614513
Property Identification Number(s) PIN's 9528-20-3732
3. Approximate date land-disturbing activity will commence: upon approval
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):2.73
6. Amount of fee enclosed: $ 1 ,100.00 . 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 Enclosed yes
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Greg Thomasson E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Greg A.Thomasson and wife Cynthia A.Thomasson 828-335-6405
Name Telephone
PO Box 892
Current Mailing Address Current Street Address
etowah NC 28792
City State Zip City State Zip
10. Deed Book No. 4186 Page No. 202 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.
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N�ame0 / E-mail Address
T0.'acne 892 L420 Tap +LA.
Current Mailing Address Current Street Address
+owal�, l lc '2-el 1-4 e. so,.0Ile., NC 215739
City State Zip City State Zip
Telephone C2-8� 336-44)465—
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.
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ature Date
I, ---giViaikaM.- K E , a Notary Public of the County of 1j1sürtJ
State of , hereby certify that f16N1tin ( li4Jc 4 c hf)I�S&A
appeared personally before me this day and being duly sworn acknowledge hat the above
form was executed by him.Witness my hand and notarial seal, this ai day of , 20 Cif
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