NCC230660_FRO Submitted_20230314

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 N/A in the blank.)
Part A.
1
2
Project Name Arbor at South Crossing - Demolition Package
Location of land -disturbing activity: County Guilford City or Township Greensboro
Highway/Street802 W. Florida St. Latitude(decimaldegrees) 36.053 Long ltude(decimaldegrees) -79.803
3. Approximate date land -disturbing activity will commence: Summer 2022
4
5
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22.32
6. Amount of fee enclosed 3,495 + 1,000 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, after which 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.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James M. Cox E-mail [e-mail]
Phone: Office # 336-303-3004 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Housing Authority of the City of Greensboro 336.275.8501
Name Phone: Office # Mobile #
450 N. Church Street 450 N. Church Street
Current Mailing Address
Greensboro, NC 27401
City
State
Zip
Current Street Address
Greensboro, NC 27401
City
State
Zip
10. Deed Book No. 1041 Page No. 218 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Housing Authority of the City of Greensboro
Company Name
450 N. Church Street
Current Mailing Address
Greensboro, NC 27401
City State Zip
Phone: Office # 336-275-8501
[e-mail]
E-mail Address
450 N. Church Street
Current Street Address
Greensboro, NC 27401
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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:
Timmons Group
Engineering firm or other consultant
Adam Carroll
[e-mail]
E-mail Address
336-478-3346 336-404-5583
Individual contact person (type or print) Phone: Office # 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.
James M. Cox
President/CEO
Type or print nam Title or Authority
�12 0 zS
S' Date
I, l�"1� 'f 1\ J, '�aqP/ a Notary Public of the County of h a mc?,,
State of North Carolina, hereby certify that �(�,� I"l W� appeared personally
before me this day and being duly sworn acknowledged t the above form was executed by him/her.
Witness my hand and notarial seal, this m day Af n UA 22
ry
MERE" J. DAYE My �mmission expires'
Notary Public • North Carolina
ALAMANCE COUNTY
My.Commlroon Expires

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:
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 3 of Record:
Phone: Office # Mobile #
Name
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 4 of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City
Phone: Office #
Company 3 Name
E-mail Address
Current Street Address
State Zip City State
Mobile #
E-mail Address
Zip
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #