NCC232940_FRO Submitted_20230928

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7 HENOEa - FINANCIAL RESPONSIBILITY/OWNERSHIP FORM NENDE �'UN7Y
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 Cottages at Mastermind
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street 102 Francis Rd Latitude 35.3454 Longitude-82.4405
Property Identification Number(s) PIN's 9579-48-2415, 9579-48-6832, 9579-49-0083
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 1
6. Amount of fee enclosed: $3500 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Gray Batten E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached.
Name Telephone
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. See attached. Page No. 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 he listed as the financially responsible party.
DHIC - Mastermind, LLC [e-mail]
Name E-mail Address
1341 Horton Circle Same
Current Mailing Address Current Street Address
Arlington TX 76011
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
CT Corporation System [e-mail]
Name E-mail Address
160 Mine Lake Court, Suite 200 Same
Current Mailing Address Current Street Address
Raleigh NC 2615
City State Zip City State Zip
Telephone [phone]
(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
27615
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.
DHIC-Mastermind,LLC,a Delaware limited liability company Vice President
By:DHI Communities II, LLC,a Delaware limited liability Title or Authority
company,its sole member y
By:Charles F. Persons
L iu„G a 2 3
Signature Date
I, 3arAle- COM e O , a Notary Public of the County of JOhn6. 01(\
State of /ip( (010kt (10• , hereby certify that Char\es \ . Pt_f 0V'S
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
day U-Y1
Witness my hand and notarial seal, this �D of , 20
Nota
Seal
JAMIE CORNWELL
My commission expires )UI' , 1 V 6'0)-1"
Notary Public, North Carolina
Johnston County
My Commission Expires
June 14,2027