NCC216875_FRO Submitted_20211213

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more contiguous 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 Environment, Health, and Natural Resources.
(Please type or print and, if question is not applicable, place NIA in the blank.)
Part A.
1. Project Name Boulding Branch Phases 2 & 3
Location of land -disturbing activity: County Guilford
City or Township HIGH POINT and Highway / Street William Joseph Lane
3. Approximate date land -disturbing activity will be commenced: August 2021
4. Purpose of development (residential, commercial, industrial, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.9 Ac. +/-
6. Amount of fee enclosed $ 2,990.00
7. Has an erosion and sedimentation control plan been filed ? Yes X No
8. Person to contact should sediment control issues arise during land -disturbing activity.
a
Name Stephen J. Phillips Telephone [phone]
Landowner (s) of Record ( Use blank page to list additional owners.):
HPT Investment Holding, LLC
Name (s)
455 Second Street Fourth Floor
Current Mailing Address
Charlottesville VA 22902
City State Zip
Current Street Address
City State Zip
10. Recorded in Deed Book No. 8424 Page No. 1732
Part B.
1. Person (s) or firms (s) who are financially responsible for this land -disturbing activity (Use the blank
page to list additional persons or firms):
Thyme Properties, LLC
Name of Person (s) or Firm (s)
2255 Lewisville-Clemmons Rd. Suite C
Mailing Address
Clemmons NC
City State
Telephone [phone]
27012
Zip
Street Address
City State Zip
Telephone

2. (a) If the Financially Responsible party is not a resident of North Carolina give name and street address
of a North Carolina agent.
Name
Mailing Address
City State Zip
Telephone
Street Address
City State Zip
Telephone
(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. It the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent.
Name ot Registeredgent
Mailing Address
City State Zip
Telephone
Street Address
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
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.
Stephen J. Phillips
Type or print name
Chief Financial Officer
Title or Authority
I, fly 77 a Notary Public of the County of 755776pR ,,f
State of �. , hereby certify that (j��tn w k.) Ph,, llr p5
appeazed persona y before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 171P) day of Jembet— ,20 c3� I —
Seal N
My commission expires ? 0? / 0?00?4;?1
Jennifer Jakows
Notary Public
j Maricopa County, Arizona
My Comm. Expires 08-21-22
Commission No. 552739