NCC220778_FRO Submitted_20220218

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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: Villas at Strawberry Creek
2. Location of land -disturbing activity: 4007 and 4015 Straw Hat Road
3. Approximate date land disturbing activity will be commenced: Janua
4. Development type: Commercial_ Industrial_ Institutional_
5. Approximate acreage of land to be disturbed: 8.2
6. Has an erosion and sediment control plan been filed? Yes ✓ No.
2022
MF residential ✓ SF residential
7. Landowner(s) of Record (attach pages to list additional owners):
Land Acquisiton and Development Servies, LLC [phone] [e-mail]
Name Telephone Email
PO Box 9147
Current Mailing Address
Greensboro N.C. 27429
City State Zip
8. Deed County: Guilford
5603 New Garden Village Drive
Current Physical Street Address
Greensboro N.C. 27410
City State Zip
Book: 8356
Page: 260
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: David Michaels
E-mail: [e-mail]
Part B:
Telephone: [phone]
Other:
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 Acquisiton and Development Servies, LLC [phone] [e-mail]
Name Telephone Email
PO Box 9147
Current Mailing Address
Greensboro N.C. 27429
City State Zip
5603 New Garden Village Drive
Current Physical Street Address
Greensboro N.C.
City
State
27410

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 B. Michalks
r to m
Signa ure
Company Agent
Title or Authority
/-;L /3/�/
Date
I, R 1i -lit a L6 a Notary Public of the County of Ou 1wLyd
State of q CO f j1 I !"1G'__, hereby certify that Fmyi d U y-id -nc i S
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this _,� day of LffO) " , 20 l
My Commission expires
WENDY B PAYNE
Notary Public, North Carolina
Rockingham County
My Commission Expires