NCC240217_FRO Submitted_20240130

�iEraFs xr� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HEPIDEKOs— %
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 Oak Preserve PRD
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street Old Spartanburg Rd. Latitude 35.2922 Longitude-82.4231
Property Identification Number(s) PIN's 9577883870
3. Approximate date land-disturbing activity will commence:ASAP; DEC 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.26
6. Amount of fee enclosed: $ 1200 (PAID) . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Troy Lee E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
2201 OP I LLC. (305)-509-1220
Name Telephone
20 E Sunrise HWY 20 E Sunrise HWY
Current Mailing Address Current Street Address
Valley Stream, NY 11581 Valley Stream, NY 11581
City State Zip City State Zip
10. Deed Book No.4082 Page No.597-600 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.
2201 OP I LLC [e-mail]
Name E-mail Address
20 E Sunrise HWY 20 E Sunrise HWY
Current Mailing Address Current Street Address
Valley Stream, NY 11581 Valley Stream, NY 11581
City State Zip City State Zip
Telephone[phone] 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;
Riverside Filings, LLC. [e-mail]
Name E-mail Address
176 Mine Lake Rd. Ste. 100 176 Mine Lake Rd. Ste. 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
Troy A. Lee Owner
por-print-na e Title or Authority
12/4/2023
S gn re Date
I, A.J CO-77- , a Notary Public of the County of 164-1 -0
State of lterhtote4914*/A , hereby certify that 17t07 A . Lappeared personally before me this day and being duly swn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this day of 14,1_,- ,�/r 20 2
A* ie Ai A ----
B Scott Roach N• ary
UBLIC
RutherfordCounty, NC My commission expires Hi 6 2-44.
My Commission Expires June 08,2026