NCC230382_FRO Submitted_20230213

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Straw Hat Road Water Line
2. Location of land -disturbing activity: .'DW"' " `_ION
3. Approximate date land disturbing activity will be commenced: Novemeber- December 2022
4. Development type: Commercial_ Industrial_ Institutional_ MF residential ✓ SF residential
5. Approximate acreage of land to be disturbed. 'k .3
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
Land Acquistion and Development Services, LLC [phone] Dmichaels@windsorcompameg. A S
Name Telephone Email
1007 Battleground Avenue - Suite 301 Same
Current Mailing Address Current Physical Street Address
Greensboro N.C. 27408
Same
City State Zip City State Zip
8. Deed County: Guilford Book: 8049 8597 Page: 0304 1185
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Tommy Michaels Telephone: [phone]
E-mail: [e-mail] Other:
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.
Land Acquistion and Development Services, LLC [phone] Dmichaels@windsorcompamf4. US
Name Telephone Email
1007 Battleground Avenue - Suite 301
Current Mailing Address
Greensboro N.C. 27408
City State
Zip
Same
Current Physical Street Address
City State
Zip

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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
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.
David Michaels Company Agent
Title or Authority
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a Notary Public of the County ofl-
State of ' �1 C hereby certify that
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Personally accepted before me this day and under oath acknowledged that the ab ve form was
executed by owner(s).
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Witness my hand and notarial seal, this day of iy120 421�
My Commission expires CPmm� I
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