NCC223601_FRO Submitted_20221024

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 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 Environment and Natural Resources. (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.)
Part A.
1. Project Name EVOLVE SOUTHPORT APARTMENTS
2. Location of land -disturbing activity: County_Brunswick City or Township_N/A
Highway/Street Along NC Hwy 211 Latitude_33.967 Longitude 78.108_
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development: Mixed -Use Development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 75.05
6. Amount of fee enclosed: $ 76*100 = $7600 . The application fee of $ 100.00 per rounded acre
is assessed without a ceiling amount. NOTE: Fees are rounded up to the next whole acre and need to
be paid by separate checks to NCDENR.
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 Matt Rogers [e-mail]
Address 2918 Martinsville Road, Suite A Greensboro NC 27408 Telephone [phone]
Cell# n/a Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone
Current Mailing Address
Current Street Address
Fax Number
City State Zip City State Zip
10. Deed Book No. 4669 Page No. 0964 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Evolve at St James, LLC
Name
[phone] 910-791-6760
Telephone Fax Number
2918 Martinsville Road, Suite A Same as Mailing Address
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City State Zip

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 Fax Number
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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 fort Financially Responsible Person). I agree to provide corrected information should there be
any change in e nforrn�tion prq jided herein.
Type or
Sig
Manager
Title or Authorit
$ 30.2�
Date
I A? 4 a I 6N0fW , a Notary Public of the County of /V ,eG(Ja���� r
State of North Carolina, hereby certify that t L1CUL l 1A - A4 61"y 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 day of Ajj 4 -f— , 20e2..?-
0
Seal
My commission expires CP -23 20 �►6