NCC215923_FRO Submitted_20211026

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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. 11RONWOOD DEVELOPMENT INC
1. Project Name ICAROLINA CROFTS - PHASE 1 SECTION 1
2. Location of land -disturbing activity: County PITT City or Township GREENVILLE
0 NC HWY 43 N, N35.636460 E77.455334
Highway/Street Latitudeg 0 Lon itude
GRE ENVILLE, NC
3. Approximate date land -disturbing activity will commence: sEP 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): IRESIDENTIAL
PREVIOUSLY PERMITTED: 3.5 AC
5. Total acreage disturbed or uncovered (Including off -site borrow and waste areas): ADDITIONAL DISTURBANCE: 10.5 AC
PREVIOUSLY PAID: $350 ITOTAL DISTURBANCE: 14.0 AC
6. Amount of fee enclosed: $ ADD'L ENCL: $1,050 . The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name STEVE SAIEED E-mail Address [e-mail]
Telephone [phone] Cell # 910.520.4044_1 Fax # [phone]
9. Landowners of Record attach accompanied page to list additional owners):
IRONWOOD DEVELOPMENT INC
c/o BOB SINGER 1336.271.3123 336.232.9123
Name Telephone Fax Number
2000 RENAISSANCE PLAZA
230 NORTH ELM ST. SAME
Current Mailing Address Current Street Address
GREENSBORO NC 27401
City State Zip
SAME
City State Zip
10. Deed Book No. 583 Page No. 150 1 Provide a copy of the most current deed.
Part B.
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):
RENAISSANCE LIFESTYLE. LLC [e-mail]
Name E-mail Address
PO BOX 17566 3301 BENSON DR.
SUITE 103
Current Mailing Address Current Street Address
RALEIGH NC 27619 RALEIGH NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number 910.332.3687

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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 by any change in the information provided herein.
STEVE SAIEED
Ty 7T.-4
print name
Signature
CHIEF OPERATING OFFICER
Title or Authority
Date
a Notary Public of the County of � c t�v'� o
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State of North Carolina, hereby certify thatappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Page 1 of 1
STATE
fit*' FILER
1�.i .P� �.C'' f, ,1r�.�;� G. fay, rtf�
rat l C i; ,''•
NORTH Dep
CAROLINA seorelw7olS al,L
CERTIFICATE OF MERGER
I, RUFUS L EDMISTEN, Secretary of State of the State of North Carolina, do
hereby certify that on the 25th day of May, 1995, Articles of Merger, or copies of
Articles of Merger, duly authenticated by the proper officer of the state or country
under the laws of which a statutory merger was effected, were filed in this office
MERGING
(Nome of Merging Corporation) (State or Country of Ineorporation)
IRONWOOD DBVI LOPAMSM, INC. NC
INTO
i Nanw of Surviving Corporation) Otats or Com" of Imorporotion)
NPSS, CORP. NC
The name of the surviving corporation was changed by virtue of said merger
to: IRONWOOD D8VSLOJf WW, INC.
The effective time of said merger, if different from the time of filing, was. -
N/A
The surviving corporation has not fled articles of dissolution or a certificate of
withdrawal and continues to be in existence in this State as of the date of this
certificate.
I FURTHER CEI TUT that this certificate is in compliance with North
Carolina General Statutes §47-18.1 and §55-4-05 and may be recorded in the office
of the Register of Deeds in the same manner as deeds, the name of the merging
corporation(s) appearing in the "Grantor" index and the name of the surviving
corporation appearing in the "Grantee" index.
LN WZ27YESS WZMWO,F, I have
rR hereunto set my hand and affvwd my
official seal of the City of Raleigh, this
y 7th day of June, 1995.
Secretary of State
Book: 583 Page: 50 Seq. 1