NCC242055_FRO Submitted_20240709

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 Environment and Natural Resources. (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.
1. Project Name Sage Croft
2. Location of land-disturbing activity: County Union City or Township Indian Trail
Highway/Street Old Monroe Rd Latitude 35.053257 Longitude -80.654366
3. Approximate date land-disturbing activity will commence:July, 2020
4. Purpose of development(residential, commercial, industrial, institutiona, etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):20.86
6500 $1,300.00 Previously Paid
.
6. Amount of fee enclosed: $ . The application lee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes X Nc Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Earl Dickenson E-mail Address eark westbridgebuiiders.com
Telephone [phone] Cell# n/a Fax# n/a
9. Landowner(s)of Record (attach accompanied page to list additional wirers):
2Gen Holdings, LLC 804-291-8481
Name Telephone Fax Number
1207 Roseneath Road 1207 Roseneath Road
Current Mailing Address Current Street Address
Richmond VA 23230 Richmond VA 23230
City State Zip City State Zip
10. Deed Book No.5897 Page No.493 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the lard-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
2Gen Holdings, LLC [e-mail]
Name E-mail Address
1207 Roseneath Road 1207 Roseneath Road
Current Mailing Address Current Street Address
Richmond VA 23230 Richmond VA 23230
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:
Moore & Alphin, PLLC n/a
Name E-mail Address
3716 National Drive 3716 National Drive
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] Fax Number n/a
(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.
V. Earl Dickinson Ill Manager
Type or print name -rifle or Authority
Signature Date
r I, `� a"• t �v+t` n I"`CG 4 , a Notary Public of the County of I�tnm'CG
C C rw 1,41 �/t1S4 nh�
441:414-GeffeFifia; hereby certify that V. 1 -rl Ii'c N sC W )I I 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 a t�T day of Apra`I 20 20
DANIEL JUSTIN MCGREAL
NOTARY PUBLIC
REGISTRATION#7806948 Notary
COMM ALTH OF VIRGINIA
MY Ct3MTvIISSION EXPIRES
My commission expires \ 9$37aa