NCC224117_FRO Submitted_20230104

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 NIA in the blank.)
Part A.
1. Project Name 1188 at Solomon
2. Location of land -disturbing activity: County Forsyth City or Township Kernersville
Highway/Street Solomon Dr Latitude 36•077062 Longitude-80,104075
3. Approximate date land -disturbing activity will commence: 05/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.45
6. Amount of fee enclosed: $ 3,700.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2.900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Parr
Telephone [phone]
Cell #
E-mail Address chris(a),parrinvestments.com
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
1188 at Solomon LLC 336-382-4523
Name Telephone Fax Number
1813 PEMBROKE RD SUITE F
Current Mailing Address Current Street Address
Greensboro, NC 27108
City State Zip City State Zip
10. Deed Book No. 003621 Page No. 03812 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.
1188 at Solomon LLC
Name
1813 Pembroke Rd Suite F
Current Mailing Address
Greensboro, NC 27408
City State
[e-mail]
E-mail Address
Current Street Address
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:
Chris Parr [e-mail]
Name of Registered Agent E-mail Address
1813 Pembroke Rd Suite F
Current Mailing Address Current Street Address
Greensboro, NC 27408
City State Zip City State Zip
Telephone [phone] 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:
Hagen Engineering [e-mail]
Engineering firm or other consultant E-mail Address
Nolan Franz 336-646-4484
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.
Chris Parr
Type or print name
a6" P"'_'
Signature
Manager
Title or Authority
Date
1, r \�0 PJ� A `h a Notary Public of the County of
State of North Carolina, hereby certify that ChI�-I s T4r>r appeared personally
before me thi,,c��yl�dd/� duly sworn acknowledged that the above form was executed by him.
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