NCC232798_FRO Submitted_20230920

Check if this project is ARPA-funded 0
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on [e-mail] e Act, including any
activity under a common plan of development of this size as covered by the NC:C301 permit, 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 address or phone
number is unavailable,place N/A in the blank.)
Part A.
1. Project Name Cypress Grove
'If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g.. SRP-D-ARP-0121)below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Davidson City or Township Linwood
Highway/Street Jubilee Road Latitude 35.76 Longitude 80.41 -
3. Approximate date land-disturbing activity will commence: Under NOV
4. Purpose of development(residential, commercial,industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.8 AC
6. Amount of fee enclosed:$ 400 . The application fee of$100.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example:8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Ixl No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Everhart E-mail Address DanielAmypophomes.com
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
PoP Homes-GSO LLC 336-596-1753
Name Phone: Office# Mobile#
464 Rickard Drive 464 Rickard Drive
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
10. Deed Book No. 2604 Page No. 1035 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)Is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
PoP Homes-GSO LLC [e-mail]
Company Name
E-mail Address
464 Rickard Drive 464 Rickard Drive
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101_
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry,give name and street address of the Registered Agent:
Emily J Meister [e-mail]
Name of Registered Agent E-mail Address
3623 North Elm Street, Suite 200 3623 North Elm Street, Suite 200
Current Mailing Address Current Street Address
Greensboro NC 27455 Greensboro NC 27455
City State Zip City State Zip
Phone: Office# 336-378-1899 Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c)If the Financially Responsible Party is engaging in business under an assumed name,give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership,or other company not registered and doing business under an assumed name,attach a COPY
of the Certificate of Assumed Name.
Company pgA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
in�e1 tverharf Mark.}- 1V1,ana fr
Type or print name Title or Authority
Signature Date
..41^-ka,-, -7 cr DYI , a Notary Public of the County of 9UVH JcCV?
�
State of North Carolina,hereby certify that Davi 4 t Vfy' a>r--1 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,this Z1i Ihnoday of klACI 64. 20 g
/41gel/(,
Notary q 'f Q
My commission expires I7 u( io�p/
AMARION SURGEON .J
Notary Public-North Carolina
Davidson County
My Commission Expires July 17,2028

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record: N/A
Name Mobile#
Phone Office#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record: N/A
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record: N/A
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record N/A
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#