NCC240404_FRO Submitted_20240228

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. Trinity Court
1. Project Name y
2. Location of land-disturbing activity: County Orange City or Township
of Chapel Hill
Highway/Street Trinity Court Latitude N35.919406 Longitude W79.062183
3. Approximate date land-disturbing activity will commence:Winter 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.18
A check for$150.00 has already been mailed '...
6. Amount of fee enclosed: $ . 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? YeSyes&approved
No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Timmons Group; Will Altman E-mail Address [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Chapel Hill [phone]
Name Telephone Fax Number
405 Martin Luther King Jr Blvd 405 Martin Luther King Jr Blvd
Current Mailing Address Current Street Address
Chapel Hill NC 27514 Chapel Hill NC 27514
City State Zip City State Zip
10. Deed Book No.254 Page No.269 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.
Community Housing Partners Corporation [e-mail]
Name E-mail Address
448 Depot St NE 448 Depot St NE
Current Mailing Address Current Street Address
Christiansburg VA 24073 Christiansburg VA 24073
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:
Susan Ellinger [e-mail]
Name E-mail Address
2840 Plaza Place, Suite 475 2840 Plaza Place, Suite 475
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone[phone] 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:
Susan Ellinger [e-mail]
Name of Registered Agent E-mail Address
2840 Plaza Place, Suite 475 2840 Plaza Place, Suite 475
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone[phone] 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.
Jeffrey K. Reed President & CEO of CHPC
Type or p 'nt e Title or Authority
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Signature Date
I, ?) oui W e5 , a Notary Public of the County of cw-fir leS(j
t. Inca.State of hereby certify that c \€ PR ' -f K• Reed appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
•Witness my hand and notarial seal, this (okday of 1f l , 20c(
e)(2-60•thiavas2-4-rad--)
BRANDY WESELOH Notary
REGISMAION#7156893 4 .�1. 2r� 1�
COMMONWEALTH OF VIRGINIA My commission expires c J .tV r • ✓0 c)oa
MY COMMISSION EXPIRES 09/30/2027 1