NCC231315_FRO Submitted_20230504

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
I1 , pemson 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.0 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. Michaels Ridge
1. Project Name
2. Location of land-disturbing activity: County Davidson City or TownshipSilver Hill Township
Palmer RdMolloway Church Rd
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:5/1/2023
4. Purpose of development(residential,commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):4.1
6. Amount of fee enclosed: $ 500 . 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? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Everhart E-mail Address [e-mail]
Telephone[phone] Cell# 336-596-1753 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
PoP Homes - GSO LLC 336-596-1753
Name Telephone Fax Number
464 Rickard Drive 464 Rickard Drive
Current Mailing Address Current Street Address
Winstons Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
10. Deed Book No.2551 Page No.1275 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.
PoP Homes - GSO [e-mail]
Name E-mail Address
464 Rickard Drive 464 Rickard Drive
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
Telephone[phone] Fax Number
L -

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:
Emily J. Meister [e-mail]
Name E-mail Address
6323 North Elm Street Suite 200 6323 North Elm Street Suite 200
Current Mailing Address Current Street Address
Greensboro NC 27455 Greensboro NC 27455
City State Zip City State Zip
Telephone[phone] Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
1 Y`Z 1 Y cAx\ooke_ic_
Type or print Title or Aut ority
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I ( 7•=73
Signature Date
I, r t O 0.teS , a Notary Public of the County of Ci u..\ I cL
State of North Carolina, hereby certify that JCCrf-V S(1)" 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_. day of 'r'‘1 , 20
Lori Oates
Q
NOTARY PUBLIC Notary
Suitfad County,NC
My Commission Expires Ociober20,2025 My commission expires 10 - aO —ov7 j