NCC220218_FRO Submitted_20220112

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. Noland Farm Subdivision
1. Project Name
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Highway/Street Tussey Road Latitude 35d 49'4"N Longitude 80d 18'30"W
3. Approximate date land -disturbing activity will commence: 1/1/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.70
6. Amount of fee enclosed: $ 0 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jim Merrill E-mail Address [e-mail]
Telephone Cell # 704-902-1252 Fax # nla
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bailey's Ridge, LLC
Name Telephone Fax Number
1340 Creekshire Way, Ste 210 1340 Creekshire Way, Ste 210
Current Mailing Address Current Street Address
Winston Salem, NC 27103 Winston Salem, NC 27103
City State Zip City State Zip
10. Deed Book No. DE 2477 Page No. 489-492 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.
Sagamore Homes NC, Inc. [e-mail]
Name E-mail Address
1348 Westgate Center Drive, Suite 100 1348 Westgate Center Drive, Suite 100
Current Mailing Address Current Street Address
Winston Salem, NC 27103 Winston Salem, NC 27103
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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 State
E-mail Address
Current Street Address
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
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
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.
Jim Merrill V? c c�-
Type or print name Title or Authority
re
Date
a Notary Public of the County of 'bald ! (, _
State of North Carolina, hereby certify that M appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this I I day of lI, 20�__
Seal Notary Public ti
Davie
County'
my Comm. Exp. _
10-03-2023 Q
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