NCC221438_FRO Submitted_20220419

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 Environment and Natural Resources. (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.)
Part A.
1. Project Name Hawthorne at Waterside Ph I and II [BRUNS-2019-0761
2- Location of land -disturbing activity. County_ Brunswick City or Township_Leland
Highway/Street Hazels Branch and US17 Latitude_34.1934 Longitude 78.0631_
3- Approximate date land -disturbing activity will commence- February 15° 2021
4- Purpose of development (residential, commercial, industrial. institutional. etc.): Commercial
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25
6 Amount of fee enclosed: S 25*100 + 2.000 = 4,500.00 The Express Permitting application fee
is a dual charge. The normal fee of $ - - - - 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 S2,585). NOTE: Both fees
are rounded up to the next whole acre and need to be paid by separate checks to NCDENR-
7. Has an erosion and sediment control plan been filed? Yes—X_ No Enclosed
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Fa
chris. fray(iDGyolyecas-con.
Address 806 Green Valley Road, Suite 311 Telephone [phone]
Cell # same
Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners).
Hawthorne at Waterside Phase II. LLC
Name
806 Green Va lley Rd Suite 311
Current Mailing Address
336-544-6205
Telephone Fax Number
Current Street Address
Green born NC 27408 _
City State Zip City
10. Deed Book No
4741
Page No. 743
State
ME
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):
Name Hawthorne at Waterside Phase II, LLC Email cnns.fray_(5),evolvecos.com
Mailing Address 806 Green Valley Rd, Suite 311 Physical Address same
Greensboro NC 27408 same
City State Zip City State Zip
Telephone [phone] 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 -
NIA
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
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State Zip City State Zip
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:
P r ma me Engineering,inc- bsmith(a�paramunte-eng.com
Engineering Firm or other consultant E-mail Address
Branch Smith 910-791-6707
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,mdividual, 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 info7ation provided herein.
Michael Winstead ! Manager at Hawthorne at Waterside Phase II LLC
Type or print nam f. Title or Authority
Signature Date
1, _XZ2 Z �Itft P6 17 e? IW , a Notary Public of the County of Y' P t �e �
State of North Carolina, hereby certify that .1I fr &I W I/V1, N4?zn� -- 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 day of -eceoi 20
Oe
c-t
z : Noijfl
Seal c
My commission expires � �--

EVOLVE CONSTRUCTION, LLC BB&T 12861
2418-A MART INSVILLE ROAD
CRUNSBpZZO NC 27446
GREENSBORO, NC 2740$ cr.i r-, s;r 12I1 012()21
PAS"
TO THE NCDEQ s **3,900'40
ORDER OF
Three Thousand Nine Hundred and OQ11 QU" HHr.�fFMt4**�fk����r����k��4����tt�*tM�kfffff!l Rat A*f##Mt�����*�71tkM�
DOLLARS
NCDE❑
MEMO Waterside Cottages
11110

NCQE❑
Waterside Cottage
12/10/2021
12861
3,900,00
Operating Acct - BB& Waterside Cottages 3,900.00