NCC223362_FRO Submitted_20221003

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: 445 08ri %%Nw% ROA J F/Cyc
2. Location of land -disturbing activity: (,0(05 lsr� S/WM ;?Q
3. Approximate date land disturbing activity will be commenced: 5 ai ,M M 4,r Zo GZ
4. Development type: Commercial_ Industrial Institutional_ MF residential. SF residential
5. Approximate acreage of land to be disturbed: 13• S
6. Has an erosion and sediment control plan been filed? Yes)4 No
7. Landowner(s) of Record (attach pages to list additional owners):
!cone. Tfwbcr Ce- 062,1v Lt c
Name Telephone
0 P4r►c Avc 321-11 Poor
Current Mailing Address
Aew ypriL NY 10016
City State Zip
8. Deed County: eN i % /1 r
Email
Current Physical Street Address
City aZ State Zip
S Book: Y 3 Page: O t� 0 5
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name:
E-mail:
Part B:
Telephone:
Other:
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 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.
SCORE Timber EC Owner LP
Name
345 Park Ave
Current Mailing Address
New York, NY 10154
City State
212-297-1058
Telephone Email
345 Park Ave.
Current Physical Street Address
New York, NY 10154
Zip City State Zip

2 (a) If the Financially Responsible Party is not a resident of North Caroh1a, give name and street eddnyoa of the
designated North Carolina Agent:
Charlie Ripple
Name
Current Mailing Address
Charlotte, wc 28202
City State
980-006-3209 [e-mail]
Telephone Email
1447 S. Tyron St, suite 200
Current Physical Street Address
Charlotte, wc 28202
Zip City State
2]p
Financially other engaging in business under an assumed
nmme.aftoohmcopy nfthe Certificate mfAssumed Name. Uthe Financially Responsible Party iaa CorporaUon,
give name and street address of the Registered Agent:
Current Mailing Address
City State
Telephone Email
Current Physical Street Address
Zip City State
Zip
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 b«the Financially Responsible Person if aOindividual orhis 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 |OforD18t|oO should there
beany change iOthe information provided herein.
joseph winning
Type o rint name
Sig ure
VP Development
Title
Date
|. gNOtary Public of the County of
State of hereby certify that
Personally accepted before nlethis day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this 7/����2wGy0f ^ . 2
My Commission expires | \
Document acMow1W98d
OtVk da .1 Commonwealth of Pennsylvania - Notary Seal
Montgomery County
My Commission Expires November 10, 2025
—NOW TPUNG Commission Number 1410740