NCC221519_FRO Submitted_20220421

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Villas at Pinewood Townhomes
2. Location of land -disturbing activity: County Randolph City or Township Cedar Grove
Highway/Street 247 Pinewood Road Latitude(decimal degrees) 35.622793 Longltude(dacimai degrees)-79,823339
3. Approximate date land -disturbing activity will commence: April, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17.04 acres
6. Amount of fee enclosed $3,800.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
i. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ;K No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Dreyfuss, Nova Pinewood, LLC E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ulah Properties, LLC [phone]
Name
2043 Northmont Drive
Current Mailing Address
Asheboro, NC 27205
City State
Phone: Office # Mobile #
2043 Northmount Drive
Current Street Address
Asheboro, NC 27205
Zip City
State
0
10. Deed Book No, 2485 Page No, 1255 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Nova Pinewood, LLC
Company Name
206 N Spruce Street, Suite 2-13
Current Mailing Address
Winston-Salem, NC 27101-2747
City
State Zip
Phone: Office # 036) 291-8592
[e-mail]
E-mail Address
206 N Spruce Street, Suite 2-13
Current Street Address
Winston-Salem, NC 27101-2747
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
4V,a AWrds5 AMf2eF(155A1QV4 reIV, Go
Name of Registered Agent E-mail Address
ST # _%`fe-
Current Mailing Address Current Street Address
hf 1d5 G1- " fj1011
City State Zip
Phone: Office # 3Z j(ty - 0t?_
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
Stoltzfus Engineering, Inc.
Engineering firm or other consultant
Aden R. Stoltzfus, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
Phone: Office #
[phone]
Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Andrew Dr fuss
Type rrnt name
Signature
Managing Member
Title or Authority
_31
Date
NA_ S:Sk 1joXtr , a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the abo a form was executed by him/her.
Witness my hand and notarial seal, this 3 day of e.-k 20 22-
Margaret N Sisk Yoder
NOTARY PUBLIC Notary
Guilford Coun , Zaz
+fyCsionExpires My commission expires 2--�

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Pinewood Country Club, Inc. (Klaussner Services, Inc.) [phone]
Name Phone: Office # Mobile #
247 Pinewood Road 247 Pinewood Road
Current Mailing Address Current Street Address
Asheboro, NC 27205 Asheboro, NC 27205
City State Zip City State Zip
Deed Book No. 1864 Page No. 1554 Provide a copy of the most current deed.
Landowner 3 of Record:
Pinewood Country Club, Inc. (Klaussner Investment Corp.) [phone]
Name
Phone: Office # Mobile #
247 Pinewood Road
247 Pinewood Road
Current Mailing Address
Current Street Address
Asheboro, NC 27205
Asheboro, NC 27205
City State
Zip
City State Zip
Deed Book No. 1207
Page No.
362 Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.