NCC222236_FRO Submitted_20220617

VP
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
No person may initiate any land -disturbing activity covered by the Durham City -County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office. Issuance of a Land Disturbing Pen -nit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal. State.
County or Municipal governments. This office must be notified in writing of any change to the information on this farm.
PLEASE TYPE OR PRINT
1. Project name: Bronze Leaf Subdivision
2. Road location of land -disturbing activity: o railwood Drive, Millspring Ave and Bittersweet Drive
Tax Map - Block - Parcel: See Attachment "A"
3. Square footage of land to be disturbed or uncovered:
PIN: See Attachment "A"
1,023,660 (23.5 acres)
4. List below the landowner of record_ Each landowner must complete Item S.
(If there are multiple owners, please list on a separate page):
Lakefield Farm, LLC
Name
2451 Croasdaile Farm Parkway, Suite 101
Address
Durham, NC 27705
City State Zip
919-383-5575 dbeischer ardenviewrealt .corn
Telephone Fax Email
5. List the person or entity financially responsible for this land -disturbing activity: The financially responsible parry shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land-
disturbina activity and/or (2) the land owner or person in possession or control of the land when they have directly or indirectly
allowed the land -disturbing activity or have benefited from it and (3) the named party on the Land Disturbing Permit.
Lakefield Farm, LLC
Name
2451 Croasdaile Farm Parkway, Suite 101
Street Address
Durham, NC 27705
City State .Zip
919-383-5575 [e-mail]
Telephone Fax Email
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Ordinance (Ordinance)
includes, but is not limited to, the following legal obligations of the financially responsible parry:
■ Maintain a set of approved sedimentation and erosion control plans, if required, on site.
• Display permit on site.
■ Understand and implement any required plan, including the construction sequence and details.
■ Inspect, maintain and repair sedimentation and erosion control measures. especially after rainfall events.
• Provided adequate around cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
d ays.
201 E. Main St, 51" Floor, Durham, N.C. 27701 a [phone] • Fax [phone]
www.co.durhim.nc.uxlcen;

■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
6. 1,or business applicants, list below the Forth Carolina registered agent for the financially responsible entity:
Name
David Beischer
2451 Croasdaile Farm Parkway, Suite 101
Street Address
Durham NC 27705
City State Zip
919-383-5575 [e-mail]
Telephone Fax Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1) the owner of the Land Disturbing Permit when issued;
(2) responsible for ensuring compliance with the Act and Ordinance. and, (3) will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
if1�'`c2a David Beischer
Date Type or Print Name
919-383-5575 Managing Member
Telephone iax Title or Authority
[e-mail]
Email Signatur
*************************************************************************************w***-�**w**%-*,pro****%-**-0**w****;'****************
Business Applicant (Provide corporate resolution on siznatory authority)
1, 00,-1A p • W1150t-i . a Notary Public of the County off
State of -Conti CayAgA , hereby certify that
David Beischer
personally came before me this day and acknowledged that he is Managing Member
of Lakefield Farm, LLC and acknowled-ed, on behalf of Lakefield Farm, LLC
Witness my hand and official seal, this
. the due execution of the
Z5 rw
da
My commission expires ObC o , 20 23
***************************************w************************************i************0************4i*******w**
Individual Applicant
State
a Notary Public of the County of
hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this.
My commission expires
day of
Notary Public
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20
i

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner. I provide my consent for ]and -disturbing activities to occur on the property listed in
Item 2 by the person or entity 1 isted in Item 5.
David Beischer
Date Type or Print Nam6 '
919-383-5575 Managing Member
Telephone Fax Tit€e or Authority
dbeischer(cD.aardenviewrealtv.com
Email Sigmlk u 114 `
wwwwwaww>I<�N*wow**wwwwwwwwww*+ww**wwwwwwwwwww*wwwww�+wwwwwwwwwwwwww+ww*ww+wwwkaww�w�►�r*�*w+*w�www�rww�w�w�:ww�w**w*ww+w**w�w�www*w�www
Business Landowner (Provide corporate resolution on signatory authority)
I. 0ckv1� ?. Wk15�tN , allotary Public of the County of _ OV-QNu C
State of WOtA1n C OCE-A OJq , hereby ccrtify that David Beischer
personally came before me this day and acknowledged that he is Managing Member
of Lakefield Farm, LLC
and acknowledged. on behalf of Lakefield Farm, LLC
, the due execution of the foregoing instrument.
Witness my hand and official sea[, this �Z'rt�
My commission expires (A 10S . 20 23
day of
b:k:hwe:k:iw:k:hY:�w+:k:M:kww:4+:kn:yw&h+kwW#�*e:�l::k:kn:l:+w:kwww*F:w4wwWw*ww**wwwwwww:NwwApR:4**b:ryww:kww*:I:wW:F'+wwyeww w+pw Mr:Nwi We Ww Wil: o-:NMOA
Individual Landowner
I,
a Notary Pub is of the County of
State of , hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this day of
My commission expires
20
Notary Public
20
�ouiv�:, •�' ,
5E-03 Rev.07106

Bronze Leaf Subdivision
Financial Responsibility/Ownership Form
Attachment "A"
0813-55-77-1657, 0813-04-65-0554,
0813-04-64-1085,0813-02-66-1660

tt� LIMITED LIABILITY COMPANY ANNUAL REPORT
lanai;
NAME OF LIMITED LIABILITY COMPANY: Lakefield Farm, LLC
SECRETARY OF STATE ID NUMBER: 1217583 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 91
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Beischer, David D
2. SIGNATURE OF THE NEW REGISTERED AGENT:
F .ling Ott= U,e Only
E - Filed Annual Repoli
1217583
CA202108902951
3/30/2021 10 A5
Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
2451 Croasdaile Farm Parkway, Suite 101 2451 Croasdaile Farm Parkway, Suite 101
Durham, NC 27705-1466 Durham County Durham, NC 27705-1466
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Real Estate
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3• PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
2451 Croasdaile Farm Parkway, Suite 101
Durham, NC 27705-1466
5. PRINCIPAL OFFICE MAILING ADDRESS
2451 Croasdaile Farm Parkway, Suite 101
Durham, NC 27705-1466
6. Select one of the fo[lowing if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Thnmae i Rpl NAME: naviri Rpicchpr
TITLE: IIA prnhQr
ADDRESS:
NAME:
TITLE: Managing Member TITLE:
ADDRESS:
2451 Croasdaile Farm Parkway, Ste. 101 2451 Croasdaile Farm Parkway, Suite 101
Durham, NC 27705 Durham, NC 27705
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a personibusiness entity.
David Beischer 3/30/2021
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
DATE
David Beischer Managing Member
Print or Type Name of Company Official Pnnt or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division. Post Office Box 29525, Raleigh. NC 27626-0525
■