NCC216934_FRO Submitted_20211215

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Whitfield Commons #2021-1474
2. Location of land -disturbing activity: terminus of Whitfield Drive
3. Approximate date land disturbing activity will be commenced: Summer 2021
4. Development type: Commercial Industrial Institutional_ MF residential SF residential
5. Approximate acreage of land to be disturbed: 6.0 Acs.
6. Has an erosion and sediment control plan been filed? Yes v No
7. Landowner(s) of Record (attach pages to list additional owners):
Williams Land Development, Inc.
Name Telephone Email
331 High Street SW
Current Mailing Address Current Physical Street Address
Winston-Salem NC
27101
City State Zip City State Zip
8. Deed County:yy k I.�ar-d Book: S5 ha Page: 222 I — 22-6
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Dixon Pitt Telephone: [phone]
E-mail: [e-mail] Other:
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.
[e-mail]
Williams Land Development, Inc. 336-529-6927
Name Telephone Email
31 High Street SW same
Current Mailing Address Current Physical Street Address
Winston-Salem NC
City State
27101
Zip
City State Zip

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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City 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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
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.
Stephen T. Williams, Jr. President
Ty e, or print name Title or Authority
Signature Date
I, ` ,-Kon a Notary Public of the County of rorS�-K-�
State of Loom, hereby certify that r�hc� "r l,��i�r�w►5, Ste•
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s). JJ''
Witness my hand and notarial seal, this day of N 20 7,1
My Commission expires
F
ON PITT
RY PUBLIC
HCOUNTY,es 6