NCC233797_FRO Submitted_20240103

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Cedar Lane
1. Project Name
2. Location of land-disturbing activity: County Forsyth City or Township Kernersville
Highway/Street Cedar Ln 36043363 -80.050857
.
Latitude Longitude
3. Approximate date land-disturbing activity will commence: 12/1/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .38
6. Amount of fee enclosed: $ $200 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Stephen Oldham E-mail Address [e-mail]
Telephone [phone] Cell # 4077049636 Fax# /j/-�
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SITA ABODES LLC 3365776614
Name Telephone Fax Number
130 Stanley Farm Rd 130 Stanley Farm Rd
Current Mailing Address Current Street Address
Kernersville, NC 27284 Kernersville, NC 27284
City State Zip City State Zip
10. Deed Book No. 003770 Page No.03866 Provide a copy of the most current deed.
Part B.
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.
RoCo Remodeling & Design info©go4roco.com
Name E-mail Address
325 W. Mountain St #1145 325 W. Mountain St #1145
Current Mailing Address Current Street Address
Kernersville, NC 27285 Kernersville, NC 27285
City State Zip City State Zip
Telephone [phone] /�`Fax Number

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:
Name E-mail Address
/7/
//t
Current Mailing Address /7 Current Street Address
//IA
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address /; Current Street Address
/ /
City State Zip City State Zip
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 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.
Sfey k el ocd il Grs\
Type or print ria:ie _____----- Title or Authority
nat /1- 7Ic((- Zz3 i
9 Date
I, r hilt' CCALLr , a Notary Public of the County of /S L
State of North Carolina, hereby certify that {eo kW Old ha appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 1
Witness my hand and notarial seal, this f G� day of O , 20 3
PHILLIP ADAM COLEY atz„
NOTARY PUBLIC i/(44/4,
Forsyth Coun N'prth Carolina Notary
My Commissio fires 9i30l2025 Q/ I a0d�
My commission expires / mil/