NCC233391_FRO Submitted_20231114

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
P1a.rt A.Project Name Woodview Estates Lot 31
2. Location of land-disturbing activity: County Forsyth City or TownshipLewisvilIe
Highway/Street 8727 Maltese Ct. Latitude 36.0730 Longitude-80.4299
3. Approximate date land-disturbing activity will commence:1 1/1 7/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential SFD
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0'14
6. Amount of fee enclosed: $ 100.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Justin Reece E-mail [e-mail]
Telephone[phone] cell# 336-692-6147 Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Third Generation Homes LLC 336-409-0226 N/A
Name Telephone Fax Number
2625 Neudorf Rd. STE 700 2625 Neudorf Rd. STE 700
Current Mailing Address Current Street Address
Clemmons, NC, 27012 Clemmons, NC, 27012
City State Zip City State Zip
10. Deed Book No.003777 Page No.00389 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.
Third Generation Homes LLC [e-mail]
Name E-mail Address
2625 Neudorf Rd. STE 700 Clemmons, NC, 27012
Current Mailing Address Current Street Address
Clemmons NC 27012 Clemmons, NC, 27012
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Justin Reece Project Superintendent
Type or print name Title or Authority
.& A -- 7' G /_ii 11/13/2023
e?itnature Date
I, 'Reitit 1- ,k1 1"l rt CV , a Notary Public of the County of Od,UR E
State of North Carolina, hereby certify that 3`i k\ l (Zee ce' 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 k day of NOvcmbcxx , 20 23
Notary REBgt4H MITCHELL My commission expires 'n n
C1 26► 2-02:1
Notary Public,North Carolina
Davie County
My Commission Expires
May 26,2027