NCC215830_FRO Submitted_20211020

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.
1
Project Name: Eastchester Subdivision
2. Physical Address/Location:
1918 Eastchester Dr High Point
Street Address: City: State
3
4.
61
Latitude. 36.012674 Longitude.—79.982141
Approximate date land -disturbing activity will commence:
10/13/2021
Purpose of development (residential, commercial, industrial, etc.)
Residential
6. Approximate acreage of land to be disturbed or uncovered:
14.0 AC
7. Landowner(s) of Record (use blank page to list additional owners):
LEOTERRA EASTCHESTER, LLC.
Name
110-A SHIELDS PARK DR
Current Mailing Address
KERNERSVILLE, NC 27284
City, State, Zip
336-486-3653
Telephone Number
Name
NC 27265
Zip:
Current Mailing Address
City, State, Zip
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 8494 Page 2512-2514
Page
FinResFm. Page # 1

I. Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
LEOTERRA EASTCHESTER, LLC.
Name Name
110-A Shields Park Drive
Current Mailing Address Current Mailing Address
Kernersville, NC 27284
City, State, Zip City, State, Zip
336-486-3653
Telephone Number Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Signature Mailing Address
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.
Christopher Lyons Manager
Ty e or Pri t Name Title of Authority
8/30/2021
ignat re Date
I, V O)6p� + Yye, BltinV,'-r a Notary Public of the County of e oVe-o_ bum, State of North
Carolina, do hereby certify that Llior5 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 3O -- day of In a uS , 20 a
YE iiNotary Public
RA�t LA
��',, My commission expires: Vhti aqa�
0 Notary Public �o
Mecklenburg
County
My Comm. Exp.
08-26-2023 T
%, © rx�$ FinResFm. Page # 2
CA0
oir�ntmuutnitiutR�a��uv