NCC221991_FRO Submitted_20220527

DocuSfgn Envelope ID: E2C5AF87-E4BE-4D39-8502-20OB1 BFF2CD7
FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Secfion, N.C. Department of Enviformental Quality. Submit the completed form to the
appropriate Regional Dtfice. (Please type or print ancl, 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_ Sweet Bulb Lane Lots
2. Location of land -disturbing activity: Count Forsyth City or Township
Highway[Street_ Sweet B lb Latitude 36.17100 Longitude -80.29830
LL
3. Approximate date land -disturbing activity will commence." 5/25/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)'Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: S 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclose
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Casey Jeter E-mail Add,,,,_�asey-jester@centurycommun,,,es.com
Telephone- Cell # 336-408-1146 Fax
9. Lanclowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC
Name Telephone Fax Number
3091 Governors Lake Dr, STE 300
Current Mailing Address Current Street Address
Norcross NC 30071
City State Zip city State Zip
10. Deed Book No.- 74 Page No. 179 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 sheeL) If the company or Arm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Dave Hodaman [e-mail]
Name
1225 Eastchester Dr.
Current Mailing Address
Highpoint NC 27265
city State Zi p
Telephone[phone] —
E-mail Address
1225 Eastchester Dr.
Current Street Address
Highpoint NC
city State
Fax Number
27265
Zip

DocuSign Envebpe Q: E2C5AF87-E4BE-4D39-8502-20OB16FF2CD7
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 State
T�_,Ie.0 hon e
E-mail Address
Current Street Address
Zip city
Fax Number
State Zip
(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:
Dave Hodgman Dave. Hodgman@centurycommunities-com
Name of Registered Agent E-mail Address
1225 Eastichester Dr. 1225 Eastchester Dr.
Current Mailing Address Current Street Address
Highpoint NC 27265 Highpoint NC 27265
city State zip City State Zip
Telephone,336-362-621 1 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-irt-fact, or if nut 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.
Dave Hodgman
name
pavu, �O a4A,
��—igA` riie_"—_
Teddi Tate carr
Regional President
Title or Authority
8/23/2021
Date
a Notary Public of the County of Guilford
State of North Carolina, hereby certify that Dave Hodgman - 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 23rd
TEDDI TATE CARR
Electronic Notary Public
Guilford County
Sea8North Carolina
ommission Expires 7/14/2023
.day of August 2021
Notary
7/14/2023
My commission F-xpires_ —