NCC222966_FRO Submitted_20220822

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Greenwood Acres
2. Location of land -disturbing activity: County Person City or TownshipRoxboro
Highway/StreetDurham Road Latitude(decimal degrees) 36.3549 Long itude(decirrial degrees) -78.9826
3. Approximate date land -disturbing activity will commence: Summer 2022 . Residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.).
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.56 ac
6. Amount of fee enclosed $700.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8. 1 0-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 171 Enclosed [0 No 171
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name-M i ixH kA- 41 I> m i() E-mail Address MtXq
Phone: Office # Mobile# qtq__�I_4"_ _511-6__
9. Landowner(s) of Record (attach accompanied page to list additional owners):
National Home Corporation
Name Phone: Office #
4850 Tamiarni Trl N.
Current Mailing Address
Naples FL 34103-3029
City State Zip
10. Deed Book No. 1125
Current Street Address
City
Page No. 463
mo
State
01
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ias).
National Home Corporation
Company Name
4850 Tamiami Trl N.
Current Mailing Address
Naples FL 34103-3029
City State Zip
Phone: Office #
Mitch. [e-mail]
E-mail Address
Current Street Address
City State Zip
Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
State Zip
City
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Emily Meister emeisterf--Ilawfirmcarolinas.com
Name of Registered Agent
3623 North Elm St, Suite 200
E-mail Address
Current Mailing Address Current Street Address
Greensboro NC 27455
city
State Zip
City
Phone: Office# 336-378-1899 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
Of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the, engineer or other
consultant who can assist in providing any necessary information regarding the plan -and its preparation:
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
Phone: Office # Mobile #
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(s)
or his attomey-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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Mitch KaMDhuis Division President -
Type or print na e Title or Authority
Signaturg Date
1, i a Notary Public of the County of
State of North Carolina, hereby certify that lit4rll 01S —. appeared personally
before me this day and being duly sworn acknowledged that the dbove formwasexecuted by him/her.
Witness my hand and notarial seal, this _L(p day of_k�d)+ 20-zz:--
<J, 1.4
Tara Rabitz Notary
NOTARY PUBLIC
cW* County
North Carolina My commission expires C' hw
My Commission Expires November 9, 2C,-'

Continued from Items 9 & 10 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile #
Current Mailing Address Current Street Address
City state Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
State Zip
Phone: Office * - Mobile #
Current Street Address
City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile #
Current Mailing Address
City State Zip
Current Street Address
City
State
0.
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
Zip city State
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
Zip city State
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
Zip city State
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
Zip city State
Phone: Office #
Mobile #