NCC232134_FRO Submitted_20230717

FINANCIAL RE0P{JNSIB|LITY/OWNERSH|PFORM |
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land-disturbing activity on one or more acres as covered by the Soil Erosion and '
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable �
erosion and sedimentation control plan have been completed and approved by the City of Greenville, |
Engineering Department. (Please type or print and, if the question is not applicable or the e-mail address or
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phone number ie unavailable, place N/A in the b|onkj �
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Part A. '
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1� Project Name Regency Boulevard Townhomeo
2. Location of|and'dioturbing activity: County Pitt City or Towns hip-{QnaeIviIle
Highway/Street xovonny Blvd,and Blazer Dr. Latitude(d."/m"/degrees)-7r.onrn Long itudow"mmm degrees) us.00m
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3. Approximate date land-disturbing activity will commence: February2O23
4. Purpose of development(residenda|, commemkd, industha|, insdtutiona|, etc.): residential �
S. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19oo/eo
6. Amount of fee enclosed: $ 1.900.00 . The application fee cf*1UO.UO per acre ovportion �
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10'ou^a �
application fee ia $QO0).
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7. Has an erosion and sediment control plan been filed? Yes O Enclosed V.4 No O
8 Person� �
Name Scott T. AndersonE-mail Address oco#Parkconnultingg^zup.nom
Phone: Office# 252_5G54O15 Mobile#-252-258'0734
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0. Landowner(s) of Record (attach accompanied page to list additional owners): �
252-752'7101 252'531'871G �
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Name Phone: Offioa# &4obi|a# �
PO Box 5G0 631 Dickinson Ave
Current Mailing Address Current Street Address �
Greenville NC 27834 Greenville NC 27834
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City State Zip City State Zip .
10i Deed Book No. 3557 Page No. 111 Provide a copy of the most current deed.

PartB.
1. Compony(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landommoqs)is
anindkvidual(s). the name(s)of the owner(s)may be listed as the financially responsible party(ies). �
Regency Multi Family Investments, LLC thomaa@Ubno.00m
Company Name E-mail Address
PO Box 5G0 831 Dickinson Ave
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834 �
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City State Zip City State Zip �
Phone: 0ffiue# 252'752-7101 K8ubi|e# 252-531'8716
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Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the |andowno/o signed and dated written consent for the applicant tooubmita draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity. �
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business n*gietry, 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
Phone: Office# _ _ Mobile# _
Name uf Individual to Contact(if Registered Agent isacompany)
(b) If the Financially Responsible Party is not a resident of North CovnUna, give name and street address �
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of the designated North Carolina agent who io registered on the NC Secretary of State business registry:
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Name of Registered Agent E-mail Address
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Current Mailing Address Current Street Address
City State Zip City State Zip
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Phone: 0ffioe# Mobika#
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority
1dja lam
Signature Date
I, Jell vi A L' 2'1'VI . , a Notary Public of the 4 County of sPI-
State of North Carolina, hereby certify that Th M 25 ' � V` appeared personally
before me this day and being duly sworn acknowledgedc that the above form was executed by him/her.
Witness my hand and notarial seal, this L1 day of d C -$6•4' , 20 2 2
Jennifer L Harris 4,6titiVAt(A.)1 -- 6 - Actui-3
ry NOTARY PUBLIC \lotary
•,-.-• 4__,at itt County,NC
My Commission Expires AUGUST 27,2025 My commission expiresA-1444,51- 21 20ZS
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Continued from Items 0 & 10 /n Part Aof the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page aoneeded to list all landowners.
Landowner 2ofRecord:
Name Phone: Office # Mobile#
Current Mailing Address Current Street Address -- !
City State Zip CKy State Zip �
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3ofRecord:
Name Phone: Offioe# Mobile#
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Current Mailing Address Current Street Address �
City State Zip City State Zip
Deed Book No. Page No. . Provide a copy of the most current deed.
Landowner 4ofRecord:
Name Phone: Offioe# Mobile '
Current Mailing Address Current Street Address
City State Zip City State Zip �
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Deed Book No. _ Page No. Provide a copy of the most current deed. �
Landowner 5ofRecord: �
Name Phone: 0Mioe# yWobi|e#
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Current Mailing Address Current Street Address �
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City State Zip City State 2]p
Deed Book No, Page No. Provide a copy of the most current deed.

Continued from Item Yin Part Bof the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page ao needed holist all financially responsible parties.
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Company 2Name E-mail Address
Current Mailing Address Current Street Address
City State Zip city State Zip �
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Phone: Office# Mobile#
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Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: {)ffice# Mobile#
Company Name E-mail Address
Current Mailing Address Current Street Address
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City State Zip City State Zip
Phone: Office# Mobile#