NCC222303_FRO Submitted_20220701

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY?OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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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 NIA in the blank).
Part A:
1. Project Narne: Sprina Street A artments
2. Location of land -disturbing activity: 523 N Sgdgg Street
3. Approximate date land disturbing activity will be commenced: April 15, 2022
4. Development type- Commercial Industrial Institutional MF residential SF residential__
5. Approximate acreage of land to be disturbed, 2.69
6. Has an erosion and sediment control plan been filed? Yes No
7. Landowner(s) of Record (attach pages to list additional owners):
523 N. Spring Street LLC
Name
3150 N Elm Street Suite 206
Current Mailing Address
Greensboro NC 27408
City State Zip
8. Deed County:
336.282.1590 srmarshall@lindbrook.c(H
Telephone Email
Same
Current Physical Street Address
City State Zip
Book: Page:
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Seth Marshall
E-mail: srmarshall0lindbrook.com
Part B:
Telephone: [phone]
Other:
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.
523 N. Spring Street LLC
Name
3150 N Elm Street Suite 206
Current Mailing Address
Greensboro NC 27408
City State Zip
336-282.1580 [e-mail]
Telephone Email
Same
Current Physical Street Address
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.
C _GY1G!�t�
4Typer print name Title or Au ority
.-O(ozz
-
ure Date
a Notary Public of the County of
State of kh i oa. , hereby certify that ( �
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
4L
Witness my hand and notarial seal, thisEday of , 20.
My Commission expires - d R-11 � 6 .
cad B. Banner
Notary Public
Guilford County, NC
My Commission Expires duly 12, 2022