NCC240033_FRO Submitted_20240108

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 Department. (Please type or print and, if the question is not applicable or the e-mail address or
phone number ia unavailable, place N/A in the b|ankj
Part A.
1, Project Name CypnesmG|en Expansion
2. Location of|and'dinturbing activity: County Pitt City or Township Greenville
Highway/Street 207 Hickory St Leh1ude(dec/mmueg°ee") 35.8109Longitude(d"cimaldegrees) -77.3478
' 8. Approximate date land-disturbing activity will commence: Nov 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Co[nDle[Cia|
5. Total acreage disturbed oruncovered (including off-site borrow and waste anaaa): 17 S
8. Amount of fee enclosed: $ 1800 . The application fee of$1O0.O0 per acre nrportion
thereof (rounded up to the next acne) is assessed without a ceiling amount (Example: 8.10'acne
application fee io8SOO).
7. Has an erosion and sediment control plan been filed? Yea EX Enclosed [] No O
O. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Eric Deal E-mail Address edeai(cDunnrh.orq
Phnne: Of5oe# 252-830-0036 Mobile# [phone]
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Cypress Glen Retirement Community 252830-0030
Name Phone: Offioe# Mobile#
1OO Hickory Street
Current Mailing Address Current Street Address
Greenville, NC 27858
City State Zip City State Zip
10. Deed Book No. 696 Page No. 164 Provide o copy oy the most current deed.

PartB.
1. Compony(ieo)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied pagajIf the company isa sole proprietorship orif the lando=ne,(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Cypress Glen-Retirement Community
Company Name E-mail Address
10UHickorvStreet
Current Mailing Address Current Street Address
Greenville NC 27858
City State Zip City State Zip
Phone: Office# 252'830-0036 KAobi|e#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and kzconduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business negiotry, 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
Phone: Of5no# Mobile#
Name of Individual 0o Contact(if Registered Agent ioocompany)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Df5oa# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party isengaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party isan individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information in 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 anindividue|(m)
or his atbznney-in-haot, orifnot on individual, by on nMioer, dinector, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change in the information provided herein.
LauhoH. Stallings Executive Director
r print - Tid Authority
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Zn a Otu�-4re Date
\. � �V�fl�' "~�' �Y�4 �Yl ���r� . a Notary Public of the County of
State of North Carolina, hereby certify that H ' 647a// appeared personally
before nne this day and being duly sworn acknowledged that the above for hYvvaoexecuted byhim/her.
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Witness my hand and notarial aeo|, this m� , deyof �]^' . 20
Notary
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q My commission expires
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