NCC224115_FRO Submitted_20221213

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: Whitefield Commons #2022-2009
2. Location of land -disturbing activity: 605 Whitfield Drive
3. Approximate date land disturbing activity will be commenced: Fall 2022
4. Development type: Commercial Industrial Institutional_ MF residential SF residential
5. Approximate acreage of land to be disturbed: 3.8 Acres
6. Has an erosion and sediment control plan been filed? Yes No
7. Landowner(s) of Record (attach pages to list additional owners)
Whitfield Partners LLC
919-524-0241 [e-mail]
Name
Telephone Email
4560 Leake Drive
same
Current Mailing Address
Current Physical Street Address
Jamestown NC 27282
City State Zip
City State Zip
8. Deed County: Guilford
Book: 8669 Page: 883 - 917
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Dixon Pitt
Telephone: [phone]
E-mail: [e-mail]
Other:
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.
[e-mail]
Williams Land Development, Inc. 336-529-6927
Name Telephone Email
331 High Street SW
Current Mailing Address
Winston-Salem NC 27101
City State Zip
same
Current Physical Street Address
City 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
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.
Stephen T. Williams, Jr. President
Type or print name Title or Authority
Signature Date
a Notary Public of the County of
State of tJ'0 hereby certify that
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 3�day of td 20 ZX
My Commission expires'26
DIXON PITT
NOTARY PUBLIC
FORSYTH COUNTY, NC
My Commission Expires Atl116