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HomeMy WebLinkAboutNCC232164_FRO Submitted_20230720 CCITY 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: Bennington Village - Section 4 - Phase 5 2. Location of land-disturbing activity: End of Torbay Dr. 3. Approximate date land disturbing activity will be commenced: February - March 2023 4. Development type: Commercial_Industrial Institutional_MF residential SF residential x 5. Approximate acreage of land to be disturbed: 5.5 6. Has an erosion and sediment control plan been filed? Yes X No 7. Landowner(s) of Record (attach pages to list additional owners): Mt. Hope Investments, LLC (336) 274-8531 aleonard©carrollcompanies.com Name Telephone Email P.O Box 9846 201 S. Elm Street - Ste. 201 Current Mailing Address Current Physical Street Address Greensboro NC 27429 Greensboro NC 27401 City State Zip City State Zip 8. Deed County: Book: Page: 9. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Ken Chavis Telephone: (336) 312-3506 E-mail: kchavis©cipconst.com 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. Carrolland Corporation (336) 274-8531 aleonard@carrollcompanies.com Name Telephone Email P.O. Box 9846 201 S. Elm Street - Ste. 201 Current Mailing Address Current Physical Street Address Greensboro NC 27429 Greensboro NC 27401 City State 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. Al Leonard •`'` ' CQ.J :(..v 1 VP - Carrolland Corporation Type or print name.- Title or Authority Signature- Date I, ', y \ .- , a Notary Public of the County of State of .)' 'r j ; L , hereby certify that Personally accepted before me this day and under oath acknowledged that the above form was executed by owner(s). Witness my hand and notarial seal, this ' day of ' ^---1 , 20 > My Commission expires t? STUART KAUFMAN Notary Public, North Carolina Guilford County My Corn issign Expire