NCC241513_FRO Submitted_20240517

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 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Osage Mill
2. Location of land-disturbing activity: County Gaston City or Township Bessemer City
201 S. 12th Street 35.283183 -81.283209
Highway/Street LatltUde(decimal degrees) LongitUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: October 1 , 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.85
6. Amount of fee enclosed: $500.00 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed I:1 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Laura Manville E-mail Address [e-mail]
Phone: Office# 202-871-7142 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Osage Mill Residential L.P.
Name Phone: Office# Mobile#
1501 Cottonwood Drive
Current Mailing Address Current Street Address
Glenview IL 60026
City State Zip City State Zip
10. Deed Book No.4962 Page No. 1835 Provide a copy of the most current deed.

Part B.
1. Company(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 landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Osage Mill Apartments LLC [e-mail]
Company Name E-mail Address
One Washington Mall, Suite 500 Same
Current Mailing Address Current Street Address
Boston MA 02108
City State Zip City State Zip
Phone: Office# 202-871-7141 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be d isturbed,!include with this form;'
the landowner's signed and dated written consent for the applicant to submit a 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 registry, give name and street address of the Registered Agent:
Cogency Global Inc. [e-mail]
Name of Registered Agent E-mail Address
212 South Tryon Street, Suite 1000 212 South Tryon Street, Suite 1000
Current Mailing Address Current Street Address
Charlotte NC 28281 Charlotte NC 28281
City State Zip City State Zip
Phone: Office# 866-621-3524 Mobile#
Lauren Thorne, Assistant Secretary
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
Gilbert J. Winn President of Manager of Osage Mill MM LLC
Type or prin ame Title or Authority
x�
Fs1,90\ A
Signature Date
I, i/tgit-1 1 7\(0i __ , a Notary Public of the County of S K F12ij<
BLS\ Cltrt,S /��
State of NoFt4I-Gafeftfm, hereby certify that ! 1 IQer- - T t1l 01 appeared personally
before me this day and being duly sworn acknowledged that theve form?? was executed by him/her.
Witness my hand and notarial seal, this day of ig fi" , 20
' Ow--
Notary
Seal
My commission expires 1,1 /?- )`C-
•
KELLY NOF
Notary Public
IVOMMOHWEALTH OF MASSACHUSE'rTS
My Commission Expires
December 12,2025

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
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 3 of Record:
Name Phone: Office# Mobile#
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 4 of Record:
Name Phone: Office# Mobile#
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 5 of Record:
Name Phone: Office# Mobile#
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.

Continued from Item
I in Part B of the Financial Responsibility/Ownership
esponsibility/owner a Form for multiple parties.
Attach copies parties.
of this page as needed to list all financially responsible p
Email Address
Company 2 Name
Current Street Address
Current Mailing Address Zip
State
State Zip City
City Mobile#
Phone: Office#
[e-mail]
Osage 1\ �« NiM LLC E-mail Address
Company 3 Name Same
Mal4, Suite 500
One Washington Current Street Address
Current Mailing Address Zip
MA 02�08 State City
Zip City
State
City
617_742-4500
Phone: Office#
Mobile#
E-mail Address
Company 4 Name
Current Street Address
Current Mailing Address Zip
State
State Zip City
City Mobile#
Phone: Office#
E-mail Address
Company 5 Name
Current Street Address
Current Mailing Address Zip
State
State Zip City
City Mobile#
Phone: Office#