NCC232417_FRO Submitted_20230811

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 —=
appropnate Regional Office (Please type or pnnt and, if the question is not applicable or the a-mad and/or
fax information unavailable, place N/A in the blank)
Part A. Del Webb at Caleb's Creek
Project Name
2. Location of land'dusturbing activity County Forsyth City or TownshipK@fnersvlll@
Hgnway/Street Pine Tree Lane Latitude 36.073867 Longitude-80.095043° _ -
3_ Approximate date land-disturbing activity will commence 04/18/2022 - -
4. Purpose of development(residential, commercial. industrial, institutional etc) Borrow material.
5_ Total acreage disturbed or uncovered(including off-site borrow and waste areas) 5.0 acres
6. Amount of fee enclosed. S 1750 The Express PermZU ng application fee is a dual charge
The normal tee of $100 00 per acre is assessed without a ceiing amount. In addition, the
Express Permdtmg supplement is $250 00 per acre up to eight acres, after why the Express
Permitting supplemental fee rS a fixed S2.00000 (Example 9 acres total is S2,900) NOTE Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEO
7. Has an erosion and sediment control plan been filed') yes X No Enclosed
8 Person to contact should erosion and sediment control issues arse dung land-disturbing activity
Name Debbie Joyce E-mail Address debbie [e-mail]
Telephone [phone] Cell 0 336-669-8189 Fax rx 336-230-1821
9 Landowner(s)of Record(attach accompanied page to list additional owners):
BOMA North Carolina, LLC
Name Telephone Fax Number
836 Good Hope Drive
Current Mailing Address Current Street Address
Castle Rock, CO 80108
City State Zip City Stale Zip
t 0 Deed Book No 2954 Page No 2404 Provide a copy of the most cement deed
Part B.
1 Company(res) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet )tf the company or Arm a a son Proprietorship,
the name of the owner or manager may be listed as the financially responsit a party
BOMA North Carolina LLC
Name E-mail Address
836 Good Hope Drive
Current Mailing Address Current Street Address
Castle Rock, CO 80108
City State Zip City Stale Zip
Telephone [phone] Fax Number

2 (a) If the Financially Responsible Party es not a resident of Norm Carolina, give name and street address
of trio des g'ated Norte Carolina Agent
Debbie Joyce debbie.joyce4greer-touis.com
Name E-mail Address
1110-A Dover Road 1110-A Dover Road
Current Matng Address Current Street Address
Greensboro, NC 27408 Greensboro, NC 27408
City State Zip City State Lp
Telephone [phone] Fax Number 336-230-1821
(b) If the Financially Responsible Party is a Partrershp or other person engaging m business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Finanaaly Responsible
Party is a Corporation, give name and street address of the Registered Agent
Name of Registered Agent E-mail Address
Current Marling Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, A 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
SEH of North Carolina, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Trent Imdieke 320-309.7497
Indrvdual contact person(type or print) Telephone 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 d an individual or his attorney-in-
fact, or d not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsble Person) I agree to provide corrected information should there be
any change in the information provided heron
Kory Reymann Manager
Type or print Title or uthonty
I ►� 7
Signature Date
1, Sa ( ( (k, . a Notary Public of the County of Jb h StlY1
State of Nerarearelma, hereby certify that Lvvti Ri r M Q H 4 appeared personally
before me this day and being duly sworn mat the above form was executed by him
Witness my hand and notarial seal, this day of Ar+I I 20 72
sARAM KATMAYM Cott: Notary
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