NCC221121_FRO Submitted_20220322

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Rice Creek Phase 1
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Win nabow
Highway/Street Rice Creek Pkwy SE Latitude 34.136813 Longitude-78.088745
3. Approximate date land -disturbing activity will commence: January 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): 212.00
6. Amount of fee enclosed: $ 21,200.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. 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 Steve Saieed E-mail Address [e-mail]
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town Creek Land Partners, LLC [phone]
Name Telephone Fax Number
7101 Creedmoor Rd, Ste 142 (Same as Mailing)
Current Mailing Address Current Street Address
Raleigh NC 27613 (Same as Mailing)
City State Zip City State Zip
10. Deed Book No. 03627 Page No. 0932 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.
Renaissance Lifestyle, LLC ssaieedgrenlifestylellc.com
Name
3301 Benson Drive, Ste 103
Current Mailing Address
Raleigh NC 27609
City State Zip
Telephone [phone]
E-mail Address
(Same as Mailing)
Current Street Address
(Same as Mailing)
City State Zip
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:
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:
Steve Saieed [e-mail]
Name of Registered Agent E-mail Address
(Same as Part B.1) (Same as Part B.1)
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone (Same as Part B.1)
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.
Steve Saieed
Typ print name
(- - �7 e'>' 0, /
Signature
COO
Title or Authority
Date
I, L C . e)_
ce_( a Notary Public of the County of JDk4�DY,-
State of North Carolina, hereby certify that k\g— 7)�'tQA appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my harad.•arad.no
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Seal` * *
Jd
rial seal, this
day of 20
Notary
My commission expires Mares
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