NCC222245_FRO Submitted_20220620

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 I I3A-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: Canter Creek Subdivision
2. Physical Address/Location:
Street Address: 1613 W. Lexington Avenue city: High Point State: NC zip: 27262
3. Latitude: 35.9691304 Longitude:-80.0519482
4. Approximate date land -disturbing activity will commence: 4/10/2022
5. Purpose of development (residential, commercial, industrial, etc.)
Residential Subdivision
6. Approximate acreage of land to be disturbed or uncovered: 15 ac
7. Landowner(s) of Record (use blank page to list additional owners):
Land Acquisition and
Development Services, LLC
Name Name
P.O. Box 9147
Current Mailing Address Current Mailing Address
Greensboro, NC 27429
City, State, Zip City, State, Zip
336-282-3535
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 DE 2498 Page 1392-1395
C••
Page
FinResFm. Page # 1

I . Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
Land Acquisition
and Development Services,
LLC
Name
Name
P.O. Box 9147
Current Mailing Address
Current Mailing Address
Greensboro, NC 27429
City, State, Zip
City, State, Zip
336-282-3535
Telephone Number
Telephone Number
2. Re is a , '
person or firm who is financially responsible:
Same
Signature
Mailing Address
David B. Michaels 336-207-8003
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.
David B. Michaels Company Agent
Ty e o t Title of Authority
March 29, 2022
§tffature I Date �y
I, �,ll� 1 , a Notary Public of the County of �F�tn tate of North
Carolina, do hereby certify that _t6y 1_ 9 Michael � , appeared personally before me
this day and being duly sworn acknowledged that the
the above form was executed by him.
Witness my han,fAI)gtarial seal, this 4day oflv�" , 20 �a
4,V � �%� Notary Public A It
) 3
7C N�r1 m
1 ,� 0 _ My commission expires:
�3 G
i,��',COUNTI,a``�� FinResFm. Page # 2