NCC222409_FRO Submitted_20220706

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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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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 DAVENPORT FARMS AT EMERALD PARK PHASE 7
2. Location of land -disturbing activity: County PITT City or Township GREENVILLE
Highway/Street PERIDOT/ZIRCON Latitude 35.5538N Longitude 77.4351W
3. Approximate date land -disturbing activity will commence: OCTOBER 23RD, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.46
6. Amount of fee enclosed: $ 750.00 , The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7, Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name LANDON WEAVER E-mail Address LWEAVER0,BILLOLARKHOMES.COM
Telephone [phone] Cell # NIA Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BILL CLARK HOMES OF GREENVILLE, LLC 252-355-5805
Name Telephone Fax Number
200 EAST ARLINGTON BLVD, STE. A
Current Mailing Address Current Street Address
GREENVILLE NC 27858
City State Zip City State Zip
10. Deed Book No. 3509 Page No. 705-709 Provide a copy of the most current doed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
BILL CLARK HOMES OF GREENVILLE, LLC LWEAVERABILLCLARKHOMES.COM
Name E-mail Address
200 E. ARLINGTON BLVD, STE. A
Current Mailing Address
GREENVILLE NO 27858
Current Street Address
City State Zip City
Telephone [phone] Fax Number
State Zip

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.
E-mail Address
Current Street Address
State Zip 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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephon
E-mail Address
Current Street Address
City State Zip
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 by any change in the information provided herein.
LANCE CLANK
Typeo print- e
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MANAGER
Title or Authority
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Date
I, � "�`� W , , a Notary Public of the County of PciL
State of North Carolina, hereby certify that cA +— 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 yday of 20 vZ j
Notary
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My commission expires a O�L3
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