NCC230380_FRO Submitted_20230213

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.
1. Project Nameh Paint Housin�c _Authorit--- --------- --_
2. Location of land -disturbing activity: County ... Guilford City or Township___—_�4Point —
HighwaylStreet___ Davis Avenue---- Latitude. 35.966_ Longitude_____75.992 —
3. Approximate date land -disturbing activity will commence:__ January 1, 2021—�� —
4. Purpose of development (residential, commercial, industrial, institutional, etc.):___ Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): ---- 9_51 AC.___—_
6. Amount of fee enclosed: $___--650-- 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).
7. Has an erosion and sediment control plan been filed? Yes— _ No________ Enclosedx __
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name—Kerrace Pressley Laurel Streetj__— E-mail Address— kpressley@laurelstreetrescom —_
Telephone--704-412_3213 Cell # ___N/A __—_---- Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Housing Authority of Fligh Point
Name Telephone Fax Number
500 E. Russell Ave. 500 E. Russell Ave.
---------------------------- ----- ----- --------_._.__--__------
Current Mailing Address Current Street Address
High Point NC 27260 High Point NC27260
City State Zip City State Zip
10. Deed Book No._— 0 —__ Page No.--_—_0 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 sore
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Laurel Street Residential LLC ------ ka 1p,-- 14 r(
Name E-mail Address
_2_132 Thrift _R_oad2132 Thrift Road Suite A
Current Mailing Address Current Street Address
--�—
Charlotte _ NC28208 CharlotteNC_28208_
City--- State Zip City State Zip

Telephone------------------- 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone_--_— _—__— Fax Number
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.
_Gem_&. _�o iw2-------------- - - � 6 � ree- --- 4 6 r' ------------------
Type or print name Title or Authority
------------------------ -1 zME
�f �122�-------------
- ignature Date
I, 06\Q a Notary Public of the County of Cal _
State of North Carolina, hereby certify that—J'U --za.__—W1?A ±ll�_ __- .__ 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 .2_day of 20?0_—
Notary
MO1UE MENUES
NOTARY PUBLIC My commission expires 16(4?oz'�__
Mecklenburg County
North Carolina
My Commission ER! SMtmber 4, 2023