NCC223402_FRO Submitted_20220930

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.I (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.
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Project Name Lakeside at James Landing
Address/Location of land -disturbing activity (include Zip Code)
—Parcel: 208794, 208796, 208795, (4800, 4810 & 4820 Piedmont Parkway)
Latitude (decimal degrees) _ 36.043037' _ Longitude (decimal degrees) _-79.926362"
Approximate date land -disturbing activity will commence: September 2022
Purpose of development (residential, commercial, industrial, etc.)
Residential, Multi -Family with associated parking lots
Approximate acreage of land to be disturbed or uncovered: 4.33
Has an erosion and sedimentation control plan been filed? Yes No
Landowner(s) of Record (use blank page to list additional owners):
SFCW Properties, LLC
Name
PO BOX 16168
Current Mailing Address
_ High Point NC 27261_
City, State, Zip
_336-292-9010
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
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 8450 Page 1958
Boole 171
Page 42,43
FinResFm. Page # I

PAP,T B_
Persor(s) or fiirm(s) who are financially responsible for this land -disturbing activity:
_BSC Holdings, LLC
Name
PO BOX 16168
Currcnt Flailing Address
Nair e
Current Mailing Address
_ High Point NC 27261 �
City, State, Zip City, Mate, Zip
336-292-9010
Telephone Number Telephone Number
2. Registemd agent, if ary2 for the person or firm who is financially responsible:
Signature Flailing Address
Printed Larne Telephone Number
3. The above information is true and correct to the best of my knowledgo 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 oftl z, director, partner or attorney -in -fact, ar registered
agent with authority to execute instruments for the financially responsible party.). 1 ageee to
provide co rec.-ted information should there be any change in the information provided herein.
_Barry Siegal —Manager
'ape or Print Name Title of Authority
! C7 7
Sigt ature Date
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a Notary Public of the County of L" - P.C-?LL State of North
Carolina, do hereby certify that ,appeared personally before me
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this day azid being duly sworn acknowledged that the above furor was executed by him,
witness my hand and notariai seal, this day of c.r 4
Notary Public
Lynn freeman
NOTARY PUBLIC
�n ullford fiwnty, PVC My carrm�is ion expires:
y M Ision Exores Au uO121, 2026
FinesFm. Page # 2