NCC231120_FRO Submitted_20230420

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NORTH CAROLINA'S INTERNATIONAL CITY''
City of High Point
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Pursuant to 6.3 of the City of High Point Development Ordinance, no person may initiate any land-
disturbing activity, as that term is defined in Chapter 10 of the City of High Point Development
Ordinance, before this authorized statement of financial responsibility and/or ownership, and an
acceptable erosion and sedimentation control plan, have been completed, submitted, and approved by the
City of High Point Department of Engineering Services.
If the applicant/financially responsible party is not the owner of the land to be disturbed, the owner's
written consent (signed and dated) for the applicant/financial responsibility party to submit a draft
Erosion and Sediment Control Plan and to conduct the anticipated land-disturbing activity must be
submitted with this document.
Submit the completed form to the City of High Point Department of Engineering Services or appropriate
ACCELA Record if required
Please type or print. 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 Golden Gate at Skeet Club
2. Address/Location of land-disturbing activity (include Zip Code):
Street Address 928 Skeet Club Rd
City High Point NC Zip Code 27265
County (ies) Guilford
Latitude (decimal degrees) 36.034061 Longitude (decimal degrees) —80.025585
(for Latitude and Longitude Location, please use main entrance for the above location)
3. Approximate date land-disturbing activity will commence:
Month March Day 1 Year 2023
4. Purpose of development (residential, commercial, industrial, etc.)
Residential (17 Lot Single-Family Subdivision)
FinResFm Revised 9-2022. Page# 1

5. Total acreage of land to be disturbed or uncovered(include off-site and waste areas in acres):
Acres to be Disturbed 5.20 acres
Off-site and/or waste site to be include with this project 0.00 acres
Total Disturbed Acres (disturbed area plus off-site/or waste site) 5.20 acres
6. Is this statement of Financial Responsibility and/or Ownership submitted for(choose one):
❑✓ An initial Erosion and Sedimentation Control Plan.
A revised Erosion and Sedimentation Control Plan. If the revised submittal proposes
additional disturbance, provide additional acres
A transferred Erosion and Sedimentation Control Plan.
7. Landowner(s) of Record—Company or Individual (if needed, use attached page to list additional
owners):
BSP INVESTMENT LLC.
Landowner (List either the Company(ies) or Individual(s))
7099 TOSCANA TRACE 7099 TOSCANA TRACE
Current Mailing Address Current Street Address
SUMMERFIELD, NC 27358 SUMMERFIELD, NC 27358
City, State, Zip City, State, Zip
704-433-7561 704-433-7561
Office Telephone Number Mobile Telephone Number
[e-mail]
email Address
8. Is the Landowner(s) of Record the Financially Responsible Party also?
Yes ❑✓ No ❑ If not, "Part B" is required to be filled out.
9. Indicate book and page where deed or instrument is filed(use blank page to list additional deeds
or instruments). Copies of Deed(s) must be provided with this submittal.
Book 8611 Page 170
Book Page
10. Provide Tax PIN or Parcel Number 6893627217
11. Is this proposed disturbance within the Randleman Lake Water Shed Watershed ?
Yes ❑✓ No
*Watershed information can be found at thePOINT v20.3.2 (highpointnc.gov), under the
Environment Layer and Watershed Sublayer.
FinResFm Revised 9-2022. Page# 2

PART B.
1 (a) If the Landowner of Record is not the Financially Responsible Party for the land-
disturbing activity, provide the names of either the Company(ies) or Individual(s)
who will be financially responsible for the disturbance. If needed, list any additional
responsible parties on the 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) may be listed as the
financially responsible party(ies).
Financially Responsible Party(List either the Company(ies) or Individual(s))
Current Mailing Address Current Street Address
City, State, Zip e-mail Address
Office Telephone Number Mobile Telephone Number
1 (b) If the Financially Responsible Party is a domestic company registered on the NC Secretary
of State business registry,provide the name and street address of the Registered Agent:A
North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the Plan, the Act, or rules or orders adopted or issued
pursuant to this ordinance.
Name of Registered Company
Current Mailing Address Current Street Address
City, State, Zip e-mail Address
Office Telephone Number Mobile Telephone Number
Name of Individual to Contact(if Registered Agent is a company)
FinResFm Revised 9-2022. Page# 3

Part B continued
1 (c) If the Financially Responsible Party is an individual who is not a resident of North Carolina, you
must provide a designated North Carolina agent who is registered on the NC Secretary of State
business registry. Provide the name and street address of the Registered Agent: A North Carolina
agent must be designated in the statement for the purpose of receiving notice of compliance or non-
compliance with the Plan, the Act, or rules or orders adopted or issued pursuant to this ordinance.
Name of Registered Agent
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
Name of Individual to Contact within North Carolina(if Registered Agent is a company)
1 (d) If the Financially Responsible Party is engaging in business under an assumed name, provide name
of business under which the company is doing business as.
OR
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 DBA Name
1 (f) The Financially Responsible Party shall provide a contact person should an Erosion and
Sedimentation Control issue arise:
Pankaj Jinwala [e-mail]
Name e-mail Address
704-433-7561 704-433-7561
Office Telephone Number Mobile Telephone Number
FinResFm Revised 9-2022. Page# 4

Part B continued
2. 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 if not an individual, by an officer, director, partner or attorney-in-fact, or
registered agent with 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.
Pankaj Jinwala Registered Agent
Type or Print Name Title of Authority
,qw (
4/3/2023
igna e equired Date
Notary Information
)
I, ir, ee C. Ct vi , a Notary Public of the County of �k,l ,,,) ,
State of b(1`s; �ayo(I
do hereby certify that Part.K ci J i w&/o�, , appeared personally before me
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this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 6'4 day of 74f 1 , 20 a .
sills mn Notary Publi
.••' '••.y 'IP My commission expires: / /7 /Zo a 7
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FinResFm Revised 9-2022. Pare - 5

Continued from Item 7 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach
copies of this page as needed to list all landowners.
Additional Landowner(s) of Record
Landowner
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
Additional Landowner(s) of Record
Landowner
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
Additional Landowner(s) of Record
Landowner
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
FinResFm Revised 9-2022. Page# 6

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.
Financially Responsible Party
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
Financially Responsible Party
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
Financially Responsible Party
Current Mailing Address Current Street Address
City, State, Zip City, State, Zip
Office Telephone Number Mobile Telephone Number
e-mail Address
FinResFm Revised 9-2022. Page# 7