NCC222439_FRO Submitted_20220707

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name Alamance Ridge - Phase II
2. Location of land -disturbing activity: County Alamance City or Township Graham
Highway/Street Governor Scott Farm Road Latitude 36°03'05"N Longitude-79°20'12"N
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 49 + 11 = 60
6. Amount of fee enclosed: 3 3.185 (original) + 1,100 (additional) + 2.:000_(express)_= 6..285 The
Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is
$250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed
$2,000.00 (Example: 9 acres total is $2,585).
Has an erosion and sediment control plan been filed? Yes X No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Buddy Seymour E-mail Address bsevmour(&windsorcommercial.us
Telephone [phone] Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners)
Alamance Ridge II, LLC
Name
840 Plantation Drive
Current Mailing Address
Telephone
840 Plantation Drive
Current Street Address
Fax Number
Burlington NC 27215 Burlington NC 27215
City State Zip City State Zip
10. Deed Book No. 4264 Page No. 670 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.
Windsor Commercial Builders, LLC
Name
5603 New Garden Village Drive _
Current Mailing Address
bsey mou r@wi n dsorcommerciai. us
E-mail Address
5603 New Garden Village Drive
Current Street Address
Greensboro NC 27410 Greensboro NC 27410
City State Zip City State Zip
Telephone [phone] Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Timmons Group adam.carroll@—timmons.com _
Engineering Firm or other consultant E-mail Address
Adam Carroll [phone]
Individual contact person (type or print) Telephone
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 print name,' Title or Authority
L21e�_t� ___1 12111-2,1
nature Date
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, a Notary Public of the County of Kv—,- 15
State of North Carolina, hereby certify that h I e-7 M 131 m oo r appeared personally
before me this day and being duly sworn acknowledged that the abov6 form was executed by him.
Witness my hand and notarial seal, this
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