NCC216078_FRO Submitted_20211104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
SOIL EROSION AND SEDIMENTATION CONTROL
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 Rutledge Road Subdivision
2. Location of land -disturbing activity: County Henderson City or Township Town of Fletcher
Address of Project: Rutledge Road Latitude 35.4394 Longitude-82.5202
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.90
6. Amount of fee enclosed: $ 3,300 . Fee Schedule FY 2018-2019 is available on
Water Resources at link https://www.hendersoncountync.gov/waterresources/page/fee-
schedule-fy2019
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Street - Windsor Built Homes E-mail Address [e-mail]
40 West Broad Street, Suite 500 40 West Broad Street, Suite 500
Current Mailing Address Current Street Address
Greenville Sc 29601 Greenville Sc 29601
City State Zip City State Zip
Telephone [phone] Cell # 864-430-2995
9. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must match
Henderson County Courthouse - Land records information or provide a recorded deed:
Windsor Built Homes, Inc 864-370-9037
Name Telephone Fax Number
40 West Broad Street, Suite 500 40 West Broad Street, Suite 500
Current Mailing Address Current Street Address
Greenville Sc 29601 Greenville Sc 29601
City State Zip City State Zip
Town of Fletcher FRO.doc Revised 6-19-2018

10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firms who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) NOTE: The signature of a
corporation, or LLC must be a listed member on the formation documents on file with the
state office at https://www.sosnc.gov/search/index/corp.
Windsor Built Homes, Inc [e-mail]
Name E-mail Address
40 West Broad Street, Suite 500 40 West Broad Street, Suite 500
Current Mailing Address Current Street Address
Greenville Sc 29601 Greenville Sc 29601
City State Zip City State Zip
Telephone [phone]
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:
Riley Hoke Smart [e-mail]
Name E-mail Address
P.O. Box 1598 743 Cardwell Lane
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip City State Zip
Telephone [phone]
(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's a Corporation, give name and street address of the Registered Agent:
Rare
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
Town of Fletcher FRO.doc Revised 6-19-2018

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.
Scott Street
President - Windsor Built Homes, Inc.
Type or me Title or Authority
ignature Date
IAi Lel-� kX,I! , a Notary Public of the County of liwi"R:*4
State of North Carolina, hereby certify that ":SC.�Srr ST&J�k"T 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 5 day of % AM— 120 72A
01
ota
Seal
My commission expires
Town of Fletcher FRO.doc Revised 6-19-2018