NCC216001_FRO Submitted_20211028

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
Bailey's Ridge Subdivision -Home Construction Erosion Control
1. Project Name
3.
4.
5.
7.
91
91
Location of land -disturbing activity: County Davie City or Township shady Grove
HighwaylStreePa�ley' s Chapel Rlatitude 35. 916083 longitude-80.415949
Approximate date land -disturbing activity will commence: November 1, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): ' - -1
Amount of fee enclosed: $ 390 .00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Tim Merrill E-mail Address 7merrill@sagamorehomes. cam
Tn1o,-%hnnc 336-955-2060 Cell # 704-902-1252 Fax #
Name Telephone Fax Number
3409 rTnion Grove Road
Current Mailing Address Current Street Address
Winston Salem NC 27127
City State Zip City State Zip
10. Deed Book No. 1167 Page No. 503 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.
Sagamore Homes NC, Inc. [e-mail]
Name E-mail Address
1348 Westgate Center Drive- Suite 100
Current Mailing Address Current Street Address
WINSTON SALEM NC 27103
City State Zip City State Zip

Telephone [phone] Fax Nu
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Type or pin# name
M
Vice -President Sagamore Homes NC, Inc.
Title or Authority
'T z 3 .--)
©ate
a Notary Public of the County of�y(i
State of North Carolina~ hereby certify that , 1�'1 1�� lLl 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 day of , 20_�_.__
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FRO Supplemental Information
9. Landowners of Record:
Sagamore Homes NC, Inc.
1348 Westgate Center Drive
Winston Salem, NC 27103
[phone]