NCC216296_FRO Submitted_20211115

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SSDIMFNTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 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 and/or
fax information unavailable, place NIA in the blank.)
Park A.
1. Project Name Country Place
2. Location of land -disturbing activity: County Burke City or Township Hickory
Highway/Street Airport Rhodhiss Road Latitude 350�45�35.5°N Longitude 81 °24�47.9°W
3. Approximate date land -disturbing activity will commence: September 25, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.85
6. Amount of fee enclosed: $ 2,520 The Express Permitting application fee is a dual cherge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE' Both fees are
rounded up to the next whole acre and need t4 be paid by separate char-ks to NCnFNR,
7. Has an erosion and sediment control plan been filed? Yes N nL-_ Enclosed X
S. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name Katie Dyess E-mail Address katie.dye"Ccenturycommunitiss.com
Telephone [phone] Cell # 704.488.1100 Fax #
9. Lendowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC 704.488.1100
Name Telephone Fax Dumber
9325 Center Lake Drive Ste 160 9325 Center Lake Drive Ste 160
Current Mailing Address Current Street Address
Charlotte NC 28216 Charlotte NC 28216
City State Zip City State Zip
10. Deed Book No. 2537 Page No. 505 Provide a copy of the most current deed.
Park E.
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 sofa proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Glenn Richard Bird for WJH LLC [e-mail]
Name E-mail Address
9325 Center Lake Drive Ste 160 9326 Center Lake Drive Ste 160
Current Mailing Address Current Street Address
Charlotte NC 28216 Charlotte NC 28216
City State Zip City state zip
Telephone 98Q,556.2871 Fax Number,

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 E-mail Address
Current Mailing Address
City State Zip
Telephone
Current Street Address
City
Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attaeh 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
City State Zip City State Zip
Telephone Fax Number
(C) in order to facilitate Express PermFtUng, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) Telephone Fax Number
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 attomey-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.
Glenn Richard Bird Division Manager
Type or print name Title or Authority
Signature Date
---.___-___-__-..___� . __.�.� .�...
Az cc�ar k5 , a Notary Public of the County of N t6 I 'VXbu r
State of North Carolina, heret)y certify that C, I uI V`3 iCh ay d bif a appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 2-b day of , 20 2
=-North
TARKS
Notaryth Carolina Notary
,� 2312 �My commission expires