NCC233529_FRO Submitted_20231130

,044 CAT
c___NTY ON{ Uhi ,
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM - HeNOERs -_
HENDERS�N �
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name The Standard at Wilmont
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street 240 Wilmont Dr Latitude 35.3249 Longitude -82.4435
Property Identification Number(s)PIN's 9578-39-5229 &9579-11-8417
3. Approximate date land-disturbing activity will commence: June 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 25.0 AC
6. Amount of fee enclosed: $ 7,700 . The application fee of$300.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac= $2,900.00).
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 Stephen Keller E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Creekstone Holdings Hendersonville,LLC [phone]
Name Telephone
4545 Post.Oak Place, Suite 150 4545 Post Oak Place, Suite 150
Current Mailing Address Current Street Address
Houston TX 77027 Houston TX 77027
City State Zip City State Zip
10. Deed Book No. 3954 Page No. 116-124 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.
Creekstone Holdings Hendersonville, LLC [e-mail]
Name E-mail Address
4545 Post Oak Place, Suite 150 4545 Post Oak Place, Suite 150
Current Mailing Address Current Street Address
Houston TX 77027 Houston TX 77027
City State Zip City State Zip
Telephone [phone] Fax Number N/A

2. (a) li the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Capitol Corporate Services,Inc. [e-mail]
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 [phone]
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone -
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.
Mike as burn Member
Type or pri t n Title or Authority
5/9/v2-3
Si nature Date
I, g1) h bc f ��/� , a Notary Public of the County of WO/3►
State of 41}-)-) G,2_0/;//6_hereby certify that i f ;Ji C/ aS-hurn
sworn acknowled ed that the above
appeared personally before me this day and being du nowledged
was executed by him.
Witness my hand and notarial seal, this 9 �day of (X , 20
t ltt$ mI PI,.,
•0 ) j)i)
�; .m•
00,2" Notary
t�T�RY
y;, Rt7WC My commission expires , 1
•
.,,,,,,� se CO'
'4yN1{INMW",