NCC215270_FRO Submitted_20210920

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Act before this form has been
completed and filed with the City of High Point Engineering Department.
Please type or print and, ifquestion is not applicable, place N/A in the blank.
PART A.
Pro.j ecr Name TDB High Point Group, LLC - N Main Retail Facili ty
2. Location of land-disturbing acivity: City Hiqh Point
Highway/Street 1913 N Main Street and 1923 N Main Street
Approximate date land-disturbing activity will commence Julv 2021
Purpose of development (residential, commercial, industrial, etc.)
Commerical
5
6
7
Approximate acreage of land to be disturbed or uncovered:
Has an erosion and sedimentation control plan been filed?
1 07 AC (46,648 SF)
Yes X No
Name
Landowner(s) of Record (use blank page to list additional owners):
TDB High Point Group , LLC
Name
'121 N Crutchfield Street
Cunent Mailing Address
Dobson, NC27017
Current Mailing Address
City, State, Zip
336-386-9790
City, State, Zip
Telephone Number Telephone Number
Indicate book and page where deed or instrument is filed (use blank page to list additional deerls or
instruments):
Book Page
Page
2370
8
Book
8417
FinResFm. Page # I
J.
4.
PART'8.
2
Person(s) or firm(s) who are financially responsible for this land-disturbing activity:
TDB High Point Group, LLC
Name Name
1 21 N Crutchfield Street
Current Mailing Address
Dobson, NC27017
Current Mailing Address
City, State, Zip
336-386-9790
City. State, Zip
Telephone Number Telephone Number
Registered agent, ifany, for the person or firm who is financially responsible:
Mailing Address
Printed Name Telephone Number
The above information is true and correct to the best ofmy knowledge and beliefand was
provided by me under oath. (This form musr be signed by the financially responsible person if an
individual. or if not an individual. by an officer, director, partner or attomey-in-fact, or registered
agent with 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.
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Date
a\,{er N Cc.rd t!{ , aN otary Public of the County of 1q r'Ir.r , State of NorthI
, appeared personally before meCarolina. do hereby certily that
this day and being duly swom acknowledged that the above form was executed by him
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FinResFm. Page # 2
Signature
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Signature