NCC216734_FRO Submitted_20220105

ROCKY MOUNT
PUBLIC wORKS
111,, CEHIkk OF :I A11
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 Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
City of Rocky Mount. (Please return to Scott. [e-mail]).
Part A.
Project Name Century Complete — Flagmarsh — Phase 2
2. Location of land -disturbing activity: County Edgecombe
Address —Zoysia Road Latitude 35.951578 Longitude-77.742109
3. Approximate date land -disturbing activity will begin : FALL 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.) : Residential
5. Total acreage disturbed : 6.40
6. Amount of fee enclosed: $ $350.00 The application fee of $50.00 per acre (rounded
up to the next acre) is assessed. (Example: For a 8.3 disturbed acreage project, the fee is $450).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Alan Mooring E-mail Address alan.mooring0celiturycommunities.com
Telephone [phone] Cell # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC N/A
Name Telephone
3091 Governors Lake Drive, Suite 300 NIA
Current Mailing Address Current Street Address
Norcross GA 30071 NIA
City State Zip City State Zip
10. Deed Book No. 1730 Page No. 0981 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
WJH LLC
Name
d ave.hodq man centu communities.com
E-mail Address
3091 Governors Lake Drive, Suite 300 3091 Governors Lake Drive, Suite 300
Current Mailing Address Current Street Address

Norcross GA 30071 Norcross GA 30071
City State Zip City State Zip
Telephone [phone]
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:
Dave Hodgman dave.hod man centur communities.com
Name E-mail Address
1225 Eastchester Dr #107 1225 Eastchester Dr #107
Current Mailing Address Current Street Address
Hiqh Point_ NC 27265 High Point NC 27265
City State Zip City State Zip
Telephone {336} 362-6211
(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
NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
City
Fax Number NIA
State Zip
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.
Dave Hodgman
Tvbe er rint name
ignature
Reciional President -Mid Atlantic Re ion
Title or Authority
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Date(
1, f � j IZ� a Notary Public of the County of
State of North Carolina, hereby certify that e, t appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hire. nd
Witness my hand and notarial seal, this Z
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tyinaovember 9, 2025
day of A4 Q5+20Z
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Notary
My commission expires