NCC240757_FRO Submitted_20240319

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RECEIVED Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
FEB 14 2024
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
_AND QUALITY SECTION SEDIMENTATION POLLUTION CONTROL ACT
ASHEVILLE
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameCate Property
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Yancey City or Township Burnsville
Bolens Creek Rd 35.8963 -82.2897
Highway/Street Latltude(decimaldegrees) Long itude(decimal degrees)
3. Approximate date land-disturbing activity will commence:3/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .2
6. Amount of fee enclosed: $200 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed I] No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brooke Cate E-mail [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LHC Investments, LLC
Name Phone: Office# Mobile#
1701 Long Bow Ln
Current Mailing Address Current Street Address
Clearwater FL 33764
City State Zip City State Zip
10. Deed Book No.889 Page No.484 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
LHC Investments, LLC - bro .c4 - rvta ( - w�
Company Name IJmail Address J
1701 Long Bow Ln
Current Mailing Address Current Street Address
Clearwater FL 33764
City State Zip City Q State Zip
Phone: Office# Mobile# ( 2 ) —S-+8
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 to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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: Office* Mobile* •
Name of Individual to Contact (if Registered Agent is a company)
(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:
Se-oulcicy, On ra,v0 d 0\09 nsi-lruch ovte ctm
Name of Registered Agent E-mail Address �1
123 S i uzAni d V---01 12,3 b cQ P
Current Mailing Address C rrent Street A d uyress
�r
nS\1 h N� 2-51 I` NC 28'11+
City State Zip City State Zip
Phone: Office* Mobile* ( S) [ !0138
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an 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 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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jaejjyc, a o k 6 Cit tt, j S e j C,rli- G,� Iv1v�)t�r�r;lt�
Type br print name Title odAuthority
1111Y11/4( Ot)e
4g^nattLre Date
l o s S «le c- cl , a Notary Public of the County of P. ;de_ I I a $
State of North Carolina, hereby certify that .341 c f I;ke d r,,c Ke 6,04 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this / day of R. br..A.y , 20 ;
1 Notary Public State of Florida ► Notary
1 l Louis Sandy Mercado
My Commission HH 37,603
1 u N Expires 3/28/2027 My commission expires 3 - 2' ' `2 7

2023 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT FILED
DOCUMENT# L06000064795 Mar 02, 2023
Entity Name: LHC INVESTMENTS, LLC Secretary of State
9738475376CC
Current Principal Place of Business:
18220 SUNSET BLVD. RECEIVED
REDINGTON SHORES, FL 33708 CvC
Current Mailing Address: FEB 14 202k
18220 SUNSET BLVD. !_AND QUALITY SECTION
REDINGTON SHORES, FL 33708 US ASHEVILLE
FEI Number: NOT APPLICABLE Certificate of Status Desired: No
Name and Address of Current Registered Agent:
CATE,DEBORAH A
18220 SUNSET BLVD.
REDINGTON SHORES, FL 33708 US
The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida.
SIGNATURE:
Electronic Signature of Registered Agent Date
Authorized Person(s) Detail :
Title MGRM Title MANAGER
Name CATE,DEBORAH A Name CATE,LOGAN HARRISON
Address 18220 SUNSET BLVD. Address 1701 LONG BOW LN
City-State-Zip: REDINGTON SHORES FL 33708 City-State-Zip: CLEARWATER FL 33764-6401
Title AUTHORIZED REPRESENTATIVE
Name CATE,JACQUELINE BROOKE
Address 1701 LONG BOW LN
City-State-Zip: CLEARWATER FL 33764-6401
I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under
oath;that tam a managing member or manager of the limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 605,Florida Statutes:and
that my name appears above,or on an attachment with all other like empowered.
SIGNATURE: DEBORAH CATE MGRM 03/02/2023
Electronic Signature of Signing Authorized Person(s) Detail Date