NCC215724_FRO Submitted_20211014

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.
I. Project Name: Triangle Lake Road Commercial Site
2. Physical Address/Location:
2001 Baker Road High Point NC 27260
Street Address: City: State: Zip:
3. Latitude:
35-57'-11.1 FN Longitude: 79-57'23.23" W
4. Approximate date land -disturbing activity will commence: September 1, 2021
5. Purpose of development (residential, commercial, industrial, etc.)
Commercial
6. Approximate acreage of land to be disturbed or uncovered: 9.0 Acres
7. Landowner(s) of Record (use blank page to list additional owners):
PTI of USA, LLC
Name
7 Westmount Court
Current Mailing Address
Greensboro, NC 27410
City, State, Zip
[phone]
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
S. 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
8388 page 1238
M
Page
FinResFm. Page # 1

1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
PTI of USA, LLC
Name Name
7 Westmount Court
Current Mailing Address Current Mailing Address
Greensboro, NC 27410
City, State, Zip City, State, Zip
[phone]
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.
Anser-Javed Wareatch Managing Member
Type or P 'rtt Name Title of Authority
ignature � Date
h-/�-�"D �I/�>31��— , a Notary Public of the County of �l 1 �' o , State of North
Carolina, do hereby certify that Alfw ,J IV`-� Oo rea 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 -2-3 Y4 day of ?�40 w P_ 20�)L-.
Notary Public
:NOTARY
za:Akbar
My commission expires: D I/ ZO 2-'6
fordth)res ary 11, 2026
My commP
FinResFm. Page # 2