NCC231691_FRO Submitted_20230602

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: Skeet Club Road and Johnson Street Subdivision
2. Physical Address/Location:
Street Address:4321 Johnson Street City: High Point State: NC Zip:27265
3. Latitude: 36.038855 Longitude: -80.021426
4. Approximate date land-disturbing activity will commence: November 15th, 2021
5. Purpose of development(residential, commercial, industrial,etc.)
Residential
6. Approximate acreage of land-to-be disturbed©r uncovered: 33.06 Acres
7. Landowner(s) of Record(use blank page to list additional owners):
Leoterra Johnson Street LLC
Name Name
110-A Shields Park Drive
Current Mailing Address Current Mailing Address
Kernersville, NC 27284
City, State,Zip City, State,Zip
336-967-6260
Telephone Number Telephone Number
8. Indicate book and page where deed or instrument is filed(use blankpage to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
Book 8518 Page 991
Book Page
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PART B.
1. Person(s) or firm(s)who are financially responsible for this land-disturbing activity:
Leoterra Johnson Street LLC
Name Name
110-A Shields Park Drive
Current Mailing Address Current Mailing Address
Kernersville, NC 27284
City, State, Zip City, State,Zip
336-967-6260
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. - above iformaation 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 or Prin Name Title of Authority
11/4/2021
gn re Date
I, Robe-4- Kye 8t u+n , a Notary Public of the County of JV)ec,k)epbtAr9 , State of North
aro ina, o ere y ce i y i , 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--- -- day of fUovem ber -
Notary Public
My commission expires: 04441.S
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