NCC232076_FRO Submitted_20230710

--HENDER _j UNTY'
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
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 N/A in the blank.)
Part A.
1. Project Name Upward Crossing Drive Extension
2. Location of land-disturbing activity: County Henderson City or Township Hendersonville
Address of Project: S. Allen Road Latitude 35'2987 Longitude-82.4098
3. Approximate date land-disturbing activity will commence: August 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2
6. Amount of fee enclosed: $800 . Fee Schedule FY 2018-2019 is available on
Water Resources at link https://www.hendersoncountync.gov/waterresources/page/approved-
fees-fy-2018-2019-0.
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 Seth Peterson E-mail Address [e-mail]
P.O. Box 17437 200 East Broad Street, Suite 220
Current Mailing Address Current Street Address
Greenville SC 29606 Greenville SC 29601
City State Zip City State Zip
Telephone[phone] Cell #
9. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must match
Henderson County Courthouse - Land records information or provide a recorded deed:
John Thomas Fleming
Name Telephone Fax Number
5133 Boylston Hwy 5133 Boylston Hwy
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

Page No.42 10. Deed Book No.4011 Provide a copy of the most current deed.
Part B.
1. Person(s) or firms who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) NOTE: The signature of a
corporation, or LLC must be a listed member on the formation documents on file with the
state office at https://www.sosnc.gov/search/index/corp.
Waterleaf at Flat Rock Apartments, LLC [e-mail]
Name E-mail Address
P.O. Box 17437 200 East Broad Street, Suite 220
Current Mailing Address Current Street Address
Greenville NC 28606 Greenville NC 28601
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:
Incorp Services, Inc.
Name 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
Telephone
(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's a Corporation, give name and street address of the Registered Agent:
(Rare)
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
City of Hendersonville FRO.doc Revised 6-19-2018

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.
Paul iesi1 Manager
Ty.- • Title or Authority
•i .t /- Date
I, Ju-[' ' S JG“cf , a Notary Public of the County of Grce✓( u, 1 I.e-
So lJ •
State of Carolina, hereby certify that PCL14J - , i C- i 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 511-- day of l or, ( , 20 L 3
Notary G U
Seal
My commission expires il1.e Ce_Sf -, '74 2Y
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City of Hendersonville FRO.doc Revised 6-19-2018

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
9b. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must
match Henderson County Courthouse - Land records information or provide a recorded deed:
OM Hospitality
Name Telephone Fax Number
550 Airport Road 107 Upward Crossing Drive
Current Mailing Address Current Street Address
Fletcher NC 28732 Flat Rock NC 28731
City State Zip City State Zip
9c. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must
match Henderson County Courthouse - Land records information or provide a recorded deed:
Upward Road Hospitality
Name Telephone Fax Number
PO Box 759 0 No Address Assigned
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip