NCC232295_FRO Submitted_20230801

NC Dept of Environmental Quality
Check if this project is ARPA-funded
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JUN 12 2023
SEDIMENTATION POLLUTION CONTROL ACT �A'
No person may initiate any land-disturbing activity on one or more acres as covered by thU.kt; ihiiiij gr iOffice
activity under a common plan of development of this size as covered by the NCG01 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 Name Ashby Village Section 2 (Phases 2 and 3)
*/f this project Involves American Rescue Plan Act (ARPA) funds list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI)
2. Location of land-disturbing activity: County Lee City or Township Sanford
S Homer Blvd 35.456655 -79.129885
Highway/Street Latitude(decima1 degrees) Longitude(deamal degrees)
3. Approximate date land-disturbing activity will commence:TBD
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):35
6. Amount of fee enclosed: $3500 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brett Massey E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ashby Village Holdings, LLC [phone] [phone]
Name Phone: Office# Mobile#
5 Century Drive, Suite 210 5 Century Drive, Suite 210
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
10. Deed Book No.01668 Page No.OO2810029 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)
Ashby Village Holdings, LLC [e-mail]
Company Name E-mail Address
5 Century Drive, Suite 210 5 Century Drive, Suite 210
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
Phone: office# [phone] Mobile# [phone]
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:
URS Agents, LLC [e-mail]
Name of Registered Agent E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# [phone] Mobile#
Lauren Johnson
Name of Individual to Contact(if Registered Agent is a company)

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(res).
Ashby Village Holdings, LLC [e-mail]
Company Name E-mail Address
5 Century Drive, Suite 210 5 Century Drive, Suite 210
Current Mailing Address Current Street Address
Greenville, SC 29607 Greenville, SC 29607
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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
URS Agents, LLC [e-mail]
Name of Registered Agent E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# [phone] Mobile#
Lauren Johnson
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.
211;, - tYlafV54kk
Type or print name Title or Auority
Signature Date 1
I, b_ rah Co -3Ynf a Notary Public of the County of (7 11 V1 ife
State of SouthCarolina, hereby certify that t7?rd. 11(1+ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/
her. II
Witness my hand and notarial seal, this 1 St day o a , 204)3
DEBORAH CONANT
j,�''�- ' NOTARY PUBLIC tary
111 Stag of South Carolina /
My Commission Expires My commission expires f seve:2
May 28, 2028