NCC232754_FRO Submitted_20230920

CITY OF GREENSBORO
FINANCIAL, RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered bythe Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section nf the City ofGreensboro. (Please type
or print and, if questions are not applicable, place N/A in the b|ank),
Part A:
1 Project Name: Walkable |o
2 Location of land-disturbing aohvity� 3521 BattlegroundAww G,eensbo ,NC 27410
3, Approximate date land disturbing activity will be commenced:
4. Development type: Commercial Industrial __}nstbuhone|___K4F nauidenha|___ SF residential ___
6. Approximate acreage uf land tobedisturbed: 7.89AC
G Has an erosion and sediment control plan been filed? Yoo_ _.No____
7, Landownmr(y) of Record (attach pages to list additional ownero):
Walkable Lifestyle.. LLC _ p30>580-5877 wi|WiPponnres.nmm
Name Telephone— Email
ouou Camden Falls Circle 3500C
Current Mailing Address Current Physical Street Address
Greensboro NC 27410 Greensboro NC 27410
City State Zip City State Zip
8� Deed County: Guilford Book: 8384 _ _ Page: 1135
S, Person ho contact should erosion and sediment control issues arise during land-disturbing activity:
Name. Will Stevens Telephone: _L336)SD05977
E'mmi|� wilPpennnuo.c*m Other: .
PavtB:
1. Cmmpmny(kas) urUnn(m)who are financially responsible for the|and-distudbiogactwity(Provdeecompnehenawa
list of all responsible parties onmo attached uhn+t,) If the oonPanyor firm isa sole proprietorship the name of the owner
or manager may Vo listed osthe fif,uoxiaKy responsible party.
Walkable Lifestyle,LLC (336)580'6977 [e-mail]
Name Telephone Email
3580 Camden Falls Circle _ 3500Cmmdmn Falls Circle
Mailing ai|ing Address Current Physical StnaatAddress
Greensboro NC Q Greensboro NC 27410

2, (o) It the Financially Responsible Party is not a resident of North Candma, give name and sheet address of the
designated North Carolina Agent:
N/A
Name Telephone Email --
- _ _--__'
Curmn��o/|ingAddena Current--Physical Street Address
City State Zip city State —
Zip
(b) If the Financially Responsible Party is m Pailnemhm o,other person engaging in business under an assumed
name, attach a copy uf the Certificate of Assumed Name. |f the Financially Responsible Party imeCorpnnadon
give name and eimee udd^exsoftheReg�tenadAgent '
N/A
Name Telephone Email --'
__
(�u Mai
ling Current Physical 3hae<Address
-
City State— Zip 'city ' Stat-- -- Zip
The above information is hue and correct to the bne\ 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-
m'/aut, or if not an individuo|, by an offioer, direntur, partner, or registered agent with the authority toexecute
instruments for the Financially Responsible Person), | agree in provide corrected information should there
be any change in the information provided herein.
Will Stevens �mnuOwr
Tjpeorphntname -01 Title orAuthority ---
��--���� �`
Signature Date
- —~—
_..... _ ____-.
. a Notary Public of the County oY
�'
State of \ �n`~-� ' . hereby certify that ~/ +r f)It��
Personally aooupbrd before methis day and under oath acknowledged that the above form was
executed bVovvner(s).
Witness rny hand and notarial seal, this da, ymf �\= �lZ,
� �� _~
�WyConomioaionexpires ` ]-� / �� �+^����� '