NCC242874_FRO Submitted_20240918

FINANICIAL RESPONSIBILITY/OWNERSHIP FORM.
SEDIMENTATION POLLUTION CONTROL ACT
No pOtspil may .any lantklisturbing.ectivity on one or more acres as;00.Veraci by the Act beforethis.
term..;arid an aOceplable orosiOrrand sedimentation :Centro! plant 1.14Ve been co.mploted and epPrdved by
the [And ot2uallty Section, NC Department of Environmental Cluelity,. Submit the completed form to the
appropriate Regional. Office. (Please typ.e: Or :print :and; if the question Is not applicable or the.eRnallandi
or faxtriformatiohunavaltable„plece N/A in blank.)
Peet:A
1.. PrejeotRanie°Dijk.14ItP; ii:14Aa
a. Locattonelland4efurbing activity: County PAVIE . City or Township PARIVIINGTQN
141ghwayt-Street REItiLAND RD. Latitdde 35.994799 Longitude 40472700
A011itoxiMitte,c1ttik laricl-diStorbing de:0.0000c SUTWIBBIK 3012024
Purpoes,Ofdeveleprnent(resideritlektommerolal,industrial, institutional, et4. .R.tSIDOrtiAL.
—totalisoreagelsittlitied ar uncovered off4sIte tycirrovvenci waste :7,95 ACREg- ••• -• -•• •
: .AmOtartt of feeentiOsed; $ 8.00 . The.epplIcationfee of $100..00 per.acre,
(rOunded.up totheneXt aore is assessed without a ceiling Amount(Example:- $900.00)-.
7: Has an erosion and esdirnent controlpien been tiled? Yes No x Enclosed.
8. Pemonto contact shotild erosion andeedlitent control isSues arise during landAisturbing actiVity:
Name. Tftf sCI:004;°4 E-mailAddrats j•ereight0)4POStw9Pdh0010.0;01t.
Telepturd. 336,833,7791 ext,302 Cell# Faxiti/
lendowner(4oriieveltl(Attache ocoMpanied.page46 list adr.StIotitiowni3itY
fiROPON.ROaliSTAltli AND EllaVfLOPMENT
-„tatlidrANY..11C . 33'6-399-7197
Nettle Telephone Fax Number
11420 lisminiza1 ltdatRoad- 6420 Hampton
Current Mailing Address. Current Street Address,
• Clemisons, NC -27012 -Ciernnions, NC .27012;
.City State. Zip City State zip
10-, Dead Book No.. 0461. . •Page No., 0.517-0520 Provide a copy of the most ourrent.deed:.
Pail B.
Cornpany(io4 or firm(s): Who are ftnenelpity responsible for the land-disturbing _actiVity (Provide a
congtrehorielve Ilst Of all responsiblepattliss-on an attached,sheet.)If the company or firm fs 8,4016 pt;oprieloi,ship,
Th&name efthei--.0vighOrbf tot.inOgortigni be lItteef as the ffnww/ally rewetOtbk Party.
• .]ASTWOOI CONSTRUCTIONPA.RTNERSi LLC icEeislitonevostwoocihomeaxem
.1gaM111 Address
'..ri1*dDivialoa4980 Premier Dr..Sulte 120 1'am:1...D11+1Mb:11..3.9N Premier Dr.Suitt 120.
Ogren(Melling Address Current Street Address
fitglatiteti NC 27261 High.Rointi NC zno
City. .State Zip City StateZip
Telephone, 3-.56.487.9.1•ext.302 Pax Number

2. (a) Ii the Financially Responsible Party la not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
. .
ICIarfie EnaBAddres
Current IVIaillogAridrest Curtent Street Address
. •
City Strite Z it State:
T.eehorte Fax Number •
.itthe Financially:Responalble Party iS.45 Partnership or other person engaging in business tinder en
aSSurried name, aitaOh.0 OW Of the Certificate of Assumed Name, tine.FineiVially Aesp0nsible
Party a Corporation,give Millet end Street addrees of ttle Registered Ag•ent
•••• • -•-•-• - - •••• .......Narne.sf:ReglsteredAgent..-- • --- - -•
. •
Current Mailing Addrm 0-Ur:rad Street Address
City State Zip City state Zip
Telephone Fax Number
The abo•ve:irifOrn'rattort is•titte erid.correa to the best of my knowledg.e and belief and Ithia$prodded
by pie under oath (This form ng.ist..be7Signed by the 'Financially Responsible Person if an individual
or his attproey4ti4aci orlf.n0(0 individvaL by.an OfflOer,:director, partner,or re.g•l•stered agent with
the atitherity• extitute instruments for the Firtantially. Reaponsible Person), I agree to provide
colTected infortriatterfebould There.be..any,Menge th the InforrhatiOn provided herein.
JEFF CREIGHTON VP-•OP HOMEBUILDING
Type or ori.nt name. Title or Authority
IAA '2°21
tn.91,41 / Date -1
. . • . . . . • . • .
.. Uti$4,Pk• 1-1
, a Notary Public of the County of y. rroya
•
Stateet North•Carditria„hereby that .,3e74-freib4V\i yew klDn appeared
personelly before me this day: and being di*.sworn eanowledged tat the above form was
executed by hint.
OrVkiN Rtir
Witness ivy bend-end nOtarial Seel,this • day of. • .. 20
. .
•
' • -Notary
• Sga-1118A A. WALI rd....,
_ 0010)-Coliki My commission expires og. -- at