NCC220662_FRO Submitted_20220215

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION 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 N/A in the blank.)
Part A. Calabash Meadows Senior Living Community
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or TownshipCalabash
Highway/StreetNW Calabash Rd Latitude78.5979 Longitude33
3. Approximate date land -disturbing activity will commence: March 2022
9151
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Senior Living Apartments
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.49
Amount of fee enclosed: $575.00 . The Express Permitting application fee is a dual charge.
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 to be paid by separate checks to NCDENR.
Has an erosion and sediment control plan been filed? Yes No Enclosed^
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name -Holly Smith E-mail Address [e-mail]
Telephone[phone] cell 4919.363.1677
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ilex Calabash, LLC 919.363.1677
Name Telephone
909 Greenwood Circle
Current Mailing Address Current Street Address
Cary NC 27511
10
City
State Zip City
Deed Book No.4679 Page No.486
State
252.459.8197
Fax Number
Zip
Provide a copy of the most current deed.
Part B.
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 sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Ilex Calabash, LLC
Name
909 Greenwood Circle
Current Mailing Address
Cary NC 27511
City
[e-mail]
E-mail Address
Current Street Address
State Zip City
State
Telephone[phone] Fax Number252.459.8197
Zip

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 Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, 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 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.
Holly L. Smith Managing Member
Typ o print name Title or 7hority
i natur Date
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I, 3-) v
nt t a Notary Public of the County of
State of North Carolina, hereby certify that 111[rm L appeared personally
before me this day and being duly sworn acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this day of o 1, 20 ?JZ-
�. KEVIN VARNELL / r
Notary Public No
p®alh Carolina
Edgecombe County My commission expires N Z