NCC215438_FRO Submitted_20211004

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 and/or
fax information unavailable, place NIA in the blank.)
Part A. 1. Project Name Cottages at Piper Village Ph 2 2. Location of land -disturbing activity: County Ra nd of p 1 I,., 1 City or TownshipTri n Ity
Highway/Street Mendenhall Rd Ext Latitude35,897458 Longitude-79.994765
3. Approximate date land -disturbing activity will commence: Nov. 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 5
6. Amount of fee enclosed: $(325)('1250) . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTrent Adams
E-mail [e-mail]
Telephone[phone] cell # 336-382-3076 Fax # n1a
9. Landowner(s) of Record (attach accompanied page to list additional owners). -
Trent Adams Properties, LLC 336-382-3076 nla
Name
307 Mill St
Current Mailing Address
Winston Salem NC 27103
City
Telephone Fax Number
307 Mill St
Current Street Address
Winston Salem NC 27103
State Zip City
State
Zip
10. Deed Book No.2735 Page No.665 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.
Trent Adams Properties, LLC [e-mail]
Name E-mail Address
307 Mill St
Current Mailing Address
Winston Salem NC 27103
City
State Zip
Telephone [phone]
307 Mill St
Current Street Address
Winston Salem NC 27103
City state
Fax Number n/a
WE

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:
nla nla
Name
E-mail Address
nla
nla
Current Mailing Address
Current Street Address
nla
nla
City State Zip
City State Zip
Telephone nla
Fax Number nla
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a eopy of the Certificate of Assumed !Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Trent Adams
[e-mail]
Name of Registered Agent
E-mail Address
307 Mill St
307 Mill St
Current Mailing Address
Current Street Address
Winston Salem NC 27103
Winston Salem NC 27103
City State Zip
City State Zip
Telephone[phone]
Fax Numbernla
(c) In 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:
Summey Engineering Associates, PLLC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Christian Vestal
336-328-0902 336-328-0922
Individual contact person (type or print)
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.
Tre
Type
X.
Registered Agent
Title or Authority
gI�`1��
Date
I, �4 iL� @ _ �_ `6�� a Notary Public of the County of A �-V%
State of North Carolina, hereby certify that —rRn 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 2A_day of
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