NCC215441_FRO Submitted_20220105

FINANCIAL RESPONSIBILITY/OWNERSHIP STATEMENT
As per 15A NCAC 04B .0118 The draft Erosion and Sediment Control Plans will not be approved until
an authorized statement of financial responsibility and ownership is submitted.
As per GS 113A-54.1(a) - If the applicant is not the owner of the land to be disturbed, the owner's written
consent for the applicant to submit a draft Erosion and Sediment Control Plan and to conduct the
anticipated land -disturbing activity must be submitted with this document.
PART A.
I. Project Name: High Point University Erath Field at Williard Stadium
2. Physical Address/Location:
1020 North University Parkway High Point NC 27268
Street Address: City: State: Zip:
3. Latitude: 35`58'3M"N Longitude: 79059'44.0"W
4. Approximate date land -disturbing activity will commence: July 2021
5. Purpose of development (residential, commercial, industrial, etc.)
Installation of synthetic turf baseball field on existing baseball field
6. Approximate acreage of land to be disturbed or uncovered: 3.414
7. Landowner(s) of Record (use blank page to list additional owners):
High Point University LOA
Name Name --_=- -
1 University Parkway
Current Mailing Address Current Mailing Address
High Point, NC 27268
City, State, Zip City, State, Zip
[phone]
Telephone Number Telephone Number
8. Indicate book and page where deed or instrument is filed (use blank page to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
Book 006454 Page
Book 03050 Page
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1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
High Point University
Name Name
1 University Parkway
Current Mailing Address Current Mailing Address
High Point, NC 27268
City, State, Zip City, State, Zip
[phone]
Telephone Number Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Lie
ature Mailing Address
J&r. , 5ve ­410_�' �__ 33G - ?It'
Printed Name Telephone Number
3. 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.
Type or Print Name Title of Authority
ignature Date
I, &" M. T
, E,/2 a Notary Public of the County of ,State of North
Carolina, do hereby certify that "06 �D ccl!�jo_f , 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 �t
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My commission expires:
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