NCC215986_FRO Submitted_20211117

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.
1. Project Name
Boone's Village Subdivision - Section A
2. Location of land -disturbing activity: County Davidson City or Township.
Highway/Street 1576 Boones Cave Rd Latitude 35.785060 Longitude_
3. Approximate date land -disturbing activity will commence: September, 2021
4.
5.
6.
7.
8.
Boone
-80.445124
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.4 +/- acres
Amount of fee enclosed: $ 1365.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jessica Meyer
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Triad Land Developers, LLC 336-970-7935
Name Telephone Fax Number
P.O. Box 810 6638-A Highwy 109
Current Mailing Address Current Street Address
Southmont NC 27351 Winston-Salem NC 27107
City State Zip City State Zip
10. Deed Book No. 2449 Page No. 1024 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.
D.R. Horton [e-mail]
Name E-mail Address
2000 Aerial Center Parkway, Suite 110 2000 Aerial Center Parkway, Suite 110
Current Mailing Address Current Street Address
Morrisville NC 27560 Morrisville NC 27560
City State Zip
Telephone [phone]
City
Fax Number
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number_
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 of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Jessica Meyer
Type or print name
Si ure
-------�Or----------__..-_---.-----------------.--------------
Title or Authority
Date
a Notary Public of the County
State of North Carolina, hereby certify that 4 appeared
personally beforiq me this day and being duly sworn acknowledged that the above form was
executed by him
Witness my hand and notarial seal, thi F. 9 c
NOTARY PUBLIC
GINA K. MOTSINGER
FORS YTH COUM Y, NC
Gortmlssion Ecgrea
Seal
My commission expires x2y/2o_3