NCC232152_FRO Submitted_20230720

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 NIA in the blank).
Part A:
1. Project Name:. Friendly Center MOB
2. Location of land -disturbing activity: 3120 Northllne Ave,_ Greensboro, NC 27408
3. Approximate date land disturbing activity will be commenced: July 17, 2023
4. Development type: Commercial ✓ Industrials Institutional MF residential_ SF residential
S. Approximate acreage of land to be disturbed: 1.77
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
CBL DIVIC I, LLC
Name
2030 Hamilton Place Blvd, Suite 500
Current Mailing Address
Chattanooga TN 37421
City State Zip
Telephone Email
2030 Hamilton Place Blvd Suite 500
Current Physical Street Address
Chattanooga TN 37421
City State Zip
8. Deed County: Guilford Book: R74578 Page: 1908.1913
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: CBL DMC I, LLC (Austin -koon)
E-mail: [e-mail]
Part B:
Telephone: [phone]
Other:
1. Company(ies) or firms) 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.
CBL DMC I, LLC 919-973.6272 akoon@davismoorecapital. C. a r-1
Name Telephone Email
2501 Blue Ridge Road - Suite 330
Current Mailing Address
Raleigh NC 27607
City State Zip -
2501 Blue Ridge Road - Suite 330
Current Physical Street Address
y ess
Raleigh NC 27607
City 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:
N/A
Name Telephone
Current Mailing Address
City State
Email
Current Physical Street Address
Zip City 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:
NIA
Name
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 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
be any change in the information provided herein.
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Typ or print name
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Signature
VVVJL !
Title or Authority
Date
I, Q(h"Al b • 1'30ke'A nk , a Notary Public of the County of u)ake,
State of IVvr�k � C rb hereby certify that AU ��C , h ootl
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s). ,,
Witness my hand and notarial seal, this w day of 20�.
My Commission expires
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eCITY OF GREENSBORO
WATER RESOURCES DEPARTMENT
SEDIMENT AND EROSION CONTROL SECTION
HG UNSBORO
RESPONSIBILITY: The owner of any property within the City limits of the City of
Greensboro where a land -disturbing activity is taking place, shall be solely responsible for any
off -site damage to adjacent property or to City streets (mud and erosion in street), that may
have been caused by the lack of erosion control measures and poor maintenance. The soil
erosion measures detailed on your plans are the minimum required by the City of Greensboro.
When conditions become apparent the owner/developer may be required by the City of
Greensboro to have his/her engineers to design or redesign additional measures/devices to
assure land protection.
1. Erosion Control measures shall be installed prior to grading and according to plans or as
directed by the City of Greensboro's Erosion Control Inspector.
2. The approval of the Erosion Control plan does not mean that additional measures may
not be required to stop off -site sediment.
3. The Owner/Developer shall require the Contractor to take every reasonable precaution
throughout construction to prevent erosion of soil and sedimentation of streams, lakes,
reservoirs, other impoundments, ground surfaces or other property, as required by
Chapter 30, Soil Erosion and Sedimentation Control, of the Code of Ordinances, City of
Greensboro, North Carolina.
4. The Owner/Developer is responsible for maintaining the erosion and sediment control
devices for the duration of the construction.
a. Inspect the site after each rain and periodically to ensure workmanship is according
to plan and site is in compliance with the Erosion Control Ordinance.
b. Repair or replace damaged or inoperative devices as directed by the Soil Erosion
Inspector within a reasonable time or time set forth by the inspector.
c. Keep mud off city streets
5. If eroded soil from the site is deposited on adjacent property, public street or into a
waterway, the Owner/Developer shall be responsible for returning the adjacent property,
city street or waterway to its original condition satisfactorily to the City or the owner of
the property.
6. After placement of asphalt binder on newly constructed street the shoulder shall be
seeded within fourteen (14) days according to the Seeding Specifications.

7. Temporary or permanent groundcover shall be provided on all perimeter areas and
slopes 3:1 or greater within 7 calendar days following completion of any phase of
grading. Provide groundcover for all disturbed areas within 14 calendar days following
completion of construction or development.
8. The Owner/Developer must plan site work so stone placement on drive entrance,
driveway and parking lot can start immediately after fine grading.
9. The Owner or Responsible Party is responsible for the long-term maintenance of the
groundcover on the property. Groundcover must be maintained to a degree that
prevents soil erosion and sedimentation at all times. The City of Greensboro has the
authority to require changes in the owner's groundcover maintenance plan in order to
stop soil erosion and sedimentation at any time.
Section 30-5-5.4 (8) — Specific Civil Penalties
Any person who violates any of the provisions of this chapter, or rules or orders adopted or
issued pursuant to this chapter, or who initiates of continues a land -disturbing activity for which
an erosion control plan is required except in accordance with the terms, conditions, and
provisions of an approved plan, shall be subject to a civil penalty of up to five thousand dollars
($5000.00) per day. No penalty shall be assessed until the person alleged to be in violation has
been notified of the violation by registered or certified mail return receipt requested, or other
means. The notice shall describe the violation with reasonable particularity, give the person a
reasonable time period to correct the violation and state that failure to correct the violation will
result in assessment of a civil penalty of up to five thousand ($5000.00) per day or other
enforcement action including criminal penalties. Each day of continuing violation shall constitute
a separate violation. The city council shall determine the amount of the civil penalty to be
assessed under this subsection and shall make written demand for payment upon the person in
violation, and shall set forth in detail a description of the violation for which the penalty has been
imposed. In determining the amount of the penalty the governing body shall consider the
degree and extent of harm caused by the violation and the cost of rectifying the damage. If
payment is not received or equitable settlement reached within thirty (30) days after demand for
payment is made the matter shall be referred to the city attorney for institution of a civil action in
the name of the city in the appropriate division of the general courts of justice for recovery of the
penalty. Any sums recovered shall be used to carry out the purposes and requirements of this
chapter. A f� l
Signature: FW Date: %b Tf>
Owner (Print): Date:
Project Address: 3120 Northhline Ave, Greensboro, NC 27408