NCC221905_FRO Submitted_20220519

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 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 Division. (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 Greenville Intergenerational Community
2. Location of land -disturbing activity: County Pitt Cityor Township Greenville
Highway/Street_ NC Highway 43 Latitude 35037'50.7"N Longitude 77026'20.0"W
3. Approximate date land -disturbing activity will commence: April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential / Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 48.3 AC
6. Amount of fee enclosed: $ $4,830.00 , The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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 David L. Guy E-mail Address [e-mail]
Telephone [phone] Cell # 704-231-9934 Fax # NIA
91
Landowner(s) of Record (attach accompanied page to list additional owners):
Springshire Retirement, LLC (202)-365-3596 NIA
Name Telephone Fax Number
PO Box 26000 230 N. Elm Street, Suite 2000
Current Mailing Address Current Street Address
Greensboro NC 27420 Greensboro NC 27401
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
DB 4083 PG 145, DB 2289 PG 645,
Part B. DB 2400 PG 258
1. 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):
Springshire Retirement, LLC [e-mail]
Name E-mail Address
1030 Hartzell Street 1030 Hartzell Street
Current Mailing Address Current Street Address
Pacific Palisades CA 90272 Pacific Palisades CA 90272
City State Zip City State Zip
Telephone
(202)-365-3596 Fax Number NIA

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:
John H. Small [e-mail]
Name E-mail Address
PO Box 26000 230 N. Elm Street, Suite 2000
Current Mailing Address Current Street Address
Greensboro NC 27420 Greensboro NC 27401
City State Zip City State ZIP
Telephone [phone] Fax Number (336)-232-9124
(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:
John H. Small [e-mail]
Name of Registered Agent E-mail Address
PO Box 26000 230 N- Elm Street, Suite 2000
Current Mailing Address Current Street Address
Greensboro NC 27420 Greensboro NC 27401
City State Zip City State Zip
Telephone [phone] Fax Number (336)-232-9124
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 by any change in the information provided herein.
Springshire Retirement, LLG
By. Sprngshire Retirement community, Int., Board Chair
its member- manager Title or Authority
By. George O' arro
Signat9 7 Date
a Notary Public of the County of /10s 4° S
State of California, hereby certify that I LIr - ctr C n appeared
personally before me this day and being duly worn acknowledge hat the above form was
executed by him. II
Witness my hand and notarial seal, this day of � 4UA, (L4 20
t
0-y
JOSE JAVIER SARAVIANotary Public - CaliforniaN ary
Los Angeles CountyCommission ; 2381247
Comm. Expires Noy 2, 2025 My commission expires

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09-17-2021 GUILFORD COUNTY, NC
09:5920 AM JEFF L THIGPEN
By MARY BRd1MJ REGISTER OF DEEDS
DEPUTY-03
ASSUMED BUSINESS NAME CERTIFICATE NCGS 66-71.5
Please print legibly.
1.
The assumed business name is:
Rising Phoenix
(You may include no more than five (5) assumed business names on this form.)
2.
The real name of the person or entity engaging in business under the assumed business name is:
Springshire Retirement, LLC
SOSI D: 0710498
{Corporations, LLCs, limited partnerships must provide the exact name registered with the NC Secretary of State's office and
the SOSID number assigned at the time of formation. Go to www.ssosnc.gov/br/search to look up your information.)
3.
The nature/type of the business is: Senior Living Center
4.
The street address of the principal place of business is: (PO Boxes are not acceptable)
230 N. Elm Street, Suite 2000, Greensboro, 27401
5.
The mailing address, if different from the street address, is:
John Small, c/o Brooks Pierce, PO Box 26000, Greensboro, NC 27420
6.
The counties where the assumed business name will be used to engage in business are:
iI All 100 North Carolina counties
This certificate is signed by the owner/legal representative of the person or entity named above,
this -j 41- day of September 2021
r
1
Signature:
Printed/Typed Na George O'Garro
Title: Board Chair of Springshire Retirement Community, Inc., Managing Member of
(See instructions for who must sign for various business entity types.) Springshire Retirement, LLC
Assumed Business Name Certificate �� �{ ���'� t�(3rle�v 10.03,17