NCC242464_FRO Submitted_20240815

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Pursuant to 6.3 of the City of High Point Development Ordinance, no person may initiate any land-
disturbing activity, as that term is defined in Chapter 10 of the City of High Point Development
Ordinance, before this authorized statement of financial responsibility and/or ownership, and an
acceptable erosion and sedimentation control plan,have been completed, submitted, and approved by the
City of High Point Department of Engineering Services.
If the applicant/financially responsible party is not the owner of the land to be disturbed,the owner's
written consent(signed and dated) for the applicant/financial responsibility party to submit a draft
Erosion and Sediment Control Plan and to conduct the anticipated land-disturbing activity must be
submitted with this document.
Submit the completed form to the City of High Point Department of Engineering Services or appropriate
ACCELA Record if required.
Please type or print. If the question is not applicable or the e-mail address or phone number is unavailable,
place N/A in the blank.
PART A.
1. Project Name Lighthouse Properties Quick Service Restaurants
2. Address/Location of land-disturbing activity (include Zip Code):
Street Address 2525 Eastchester Drive
City High Point NC Zip Code 27265
County(ies) G u i lfo rd
Latitude (decimal degrees) 36.02892 Longitude(decimal degrees) -79.97146
(For Latitude and Longitude Location,please use main entrance for the above location)
3. Approximate date land-disturbing activity will commence:
Month Day Year
4. Purpose of development(residential, commercial, industrial, etc.)
Commercial
FinResFm Revised 9-2023 Page 1

5. Total acreage of land to be disturbed or uncovered (include off-site and waste areas in acres):
Acres to be Disturbed 1 '73 acres
Off-site and/or waste site to be include with this project '36 acres
Total Disturbed Acres (disturbed area plus off-site/or waste site) 2'09 acres
b. Is this statement of Financial Responsibility and/or Ownership submitted for(choose one):
An initial Erosion and Sedimentation Control Plan.
A revised Erosion and Sedimentation Control Plan.If the revised submittal proposes
additional disturbance,provide additional acres
A transferred Erosion and Sedimentation Control Plan.
7. Landowner(s) of Record—Company or Individual (if needed,use attached page to list additional
owners):
Deep River Baptist Church
Landowner(List either the Company(ies) or Individual(s))
2525 Eastchester Drive 2525 Eastchester Drive
Current Mailing Address Current Street Address
High Point, NC 27265 High Point, NC 27265
City, State,Zip City, State,Zip
336-906-0854 336-906-0854
Office Telephone Number Mobile Telephone Number
[e-mail]
Email Address
8. Is the Landowner(s) of Record the Financially Responsible Party also?
Yes No ✓ If not, "Part B" is required to be filled out.
9. Indicate book and page where deed or instrument is filed(use blank page to list additional deeds
or instruments). Copies of Deed(s) must be provided with this submittal.
Book 6558 Page 1842-1844
Book Page
10. Provide Tax PIN or Parcel Number 196569
11. Is this proposed disturbance subject a a- E .I. -man Lake Watershed Riparian Buffer
Regulations? Yes No r/
*Watershed information can be found at NCDEQ Division of Water Resources Map:
hops://experience.arcgis.com/experience/689283d17bf3=12c2a96364fbab 09aSd8/page/Page-1/?views=Layers
under the Surface Water Classifications layer and NC Riparian Buffer Areas with Rules sublayer.
FinResFm Revised 9-2023 Page 2

PART E.
I (a) >if the ILand©wnet o f Record i miot the Financially Responsible Party for the land-
disturbing activity, provide the names of either the an Compv(ie I or Individ ual(.$) who
will be financially responsible for the disturbance. If needed, list any additional
responsible parties on the accompanied page. If the company is a sole proprietorship or if
the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the
financially responsible party(ies).
Lighthouse Properties CT, L=CC
Financially Responsible Party (List either the Company(ies)or Individual(s))
2504 Vaybank Drive 2504 Maybank Drive
Current Mailing Address Current Street Address
Char lotto, NC 28211 [e-mail]
City, State, Zip Email Address
704-576=800 98 704=576=8098
Office Telephone Number Mobile Telephone Number
1 (b) If the_Financially Responsible Party is, _Iwnestic eompan/registered on the NC Secretary
of State business registry, provide the name and street address of the Registered Agent:A
North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the Plan, the Act, or rules or orders adopted or issued
pursuant to this ordinance.
Lighthouse Properties CT, L_CC
Name of Registered Company
2504 Maybank Drive 2504 IVaybank Drive
Current Mailing Address Current Street Address
Charlotte NC 2821 i cannon©Hghthouse=props.com
City, State,Zip Email Address
704=5776-8098 7704=576=°098
Office Telephone Number Mobile Telephone Number
Cannon S. Cory
Name of Individual to Contact(if Registered Agent is a company)
FinResFm Revised 9-2023 Page 3

Part B -Continued
1 (c) If the Financially Responsible Party is an individual who is not a resident of North Carolina, you
must provide a designated North Carolina agent who is registered on the NC Secretary of State
business registry. Provide the name and street address of the Registered Agent: A North Carolina
agent r��nn s1 be_il_e_N kRagea in the statement for the purpose of receiving notice of compliance or non-
compliance with the Plan, the Act, or rules or orders adopted or issued pursuant to this ordinance.
Name of Registered Agent
Current Mailing Address Current Street Address
City, State, Zip City, State,Zip
Office Telephone Number Mobile Telephone Number
Email Address
Name of Individual to Contact within North Carolina(if Registered Agent is a company)
1 (d) If the Financially Responsible Party is engaging in business under an assumed name,provide name
of business under which the company is doing business as.
I f�
If the Financially Responsible Party is an individual, General Partnership, or other company not
registered and doing business under an assumed) name,attach a copy of the Certificate of Assumed)
Name.
Company DBA Name
1 (e) The Financially Responsible Party shall provide a contact person should an Erosion and
Sedimentation Control issue arise:
Cannon S. Cory cannon@ oghthouse props com
Name Email Address
704-576=8098 704-576-8098
Office Telephone Number Mobile Telephone Number
FinResFm Revised 9-2023 Page 4

Part B - Continued
2. 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.
M
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Type or Print Name Title of Authority
eivt,-A.."-- 4 4H/r)
Signature
g Required Date
Notary Information
I, 1' b , a Notary Public of the County ,\,611Warbil
,
Py
State of W r th t,i 11 i
do hereby certify that eculnY) S. C 9
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 / 1 -11- day of 1 2ii , 20 2E4 .
Notary Public
s My commission expires: \ l
FinResFm Revised 9-2023 Page 5