NCC243307_FRO Submitted_20241028

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameColdwater Lot 26
2. Location of land-disturbing activity: County Forsyth City or Township Stokesdale
7968 Boathouse Way 36.23255 -80.0367
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1 0/28/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): •71
6. Amount of fee enclosed: $100 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJustin Reece E-mail [e-mail]
Phone: Office# 336-692-6147 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Third Generation Homes LLC 336-409-0226 336-692-6147
Name Phone: Office# Mobile#
2625 Neudorf Rd STE 700 2625 Neudorf Rd STE 700
Current Mailing Address Current Street Address
Clemmons NC 27012 Clemmons NC 27012
City State Zip City State Zip
10. Deed Book No.RE3832 Page No.880 869 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Third Generation Homes LLC [e-mail]
Company Name E-mail Address
2625Neudorf RD.STE 700 2625 Neudorf RD.STE 700
Current Mailing Address Current Street Address
Clemmons NC 27012 Clemmons NC 27012
City State Zip City State Zip
Phone: Office# 336-409-0226 Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Justin Reece VP of Construction
Typ or print name Title or Authority
%ate T G 10/25/202y
S' ature Date
?6ak-airl 1`il1kcheU , a Notary Public of the County of Oct,.\AL
State of North Carolina, hereby certify that Jv ire ,e_ct appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this Zs day of Cc \t \)CX , 20 Zy
V.QAQ0)63111 �
1 &MALL
REBEKAH MITCHELL Notary
Notary Public,North Carolina Z� 2027
Davie County My commission expires
My Commission Expires
Ma 28,2027