NCC215895_FRO Submitted_20211025

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 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.
1.
2.
3.
4.
5.
6.
7.
8.
Project Name Aurora Place
Location of land -disturbing activity: County Brunswick
Highway/Street S.R. 1406 (Bell Swamp Rd NE)
City or Township Towncreek
Latitude 34.11640 Longitude -78.12350
Approximate date land -disturbing activity will commence: As soon as permits are obtained
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 52.71
Amount of fee enclosed: $N/A (Permit Transfer). The application fee 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).
Has an erosion and sediment control plan been filed? Yes I,/ No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thomas C. Hall E-mail Address thallOwindsorinvestments.com
Telephone [phone] Cell *
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AMB Investments LLC
Name
1501 Highwoods Blvd, Ste 302
Current Mailing Address
Greensboro NC 27410
City State Zip
336-900-2405
Telephone
1501 Highwoods Blvd, Ste 302
Current Street Address
Fax Number
Greensboro NC 27410
City State Zip
10. Deed Book No.465 1. Page No. 1305 Provide a copy of the most current deed.
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.
Brunswick Area Developers, LLC
Name
5603 New Garden Village Drive
Current Mailing Address
Greensboro NC 27410
City State Zip
thall(o-),windsorinvestments.com
E-mail Address
5603 New Garden Village Drive
Current Street Address
Greensboro NC 27410
City State Zip

Telephone [phone] Fax Number
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
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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:
L. Thomas Wood, III
Name of Registered Agent
5603 New Garden Villa-ge Drive
Current Mailing Address
twood(c),windsorinvestments.com
E-mail Address
5603 New Garden Village Drive
Current Street Address
Greensboro NC 27410 Greensboro NC 27410
City State Zip City State Zip
Telephone [phone]
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.
Thomas C. Hall
Typy or print name
1.
Signature
Manage
Title or Authority
UIA I L4 IA,2011
Date J I
I, M�J/lDm C. V+WIN , a Notary Public of the County of. V,'1U,1 Nlrotfm
State of North Carolina, hereby certify that --r -1 1,
- lflrmfl� C. 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 J3_�jday of CMUL'I 2
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SealMy comrn. exp.
02-04-2023 - 1
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