NCC221740_FRO Submitted_20220505

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: Abbey Crossing
2. Physical Address/Location:
Street Address: 5085 Samet Dr.
City: High Point State: NC zip: 27265
3. Latitude: 36.026 Longitude:-79.966
4. Approximate date land -disturbing activity will commence: ASAP
5. Purpose of development (residential, commercial, industrial, etc.)
Residential
6. Approximate acreage of land to be disturbed or uncovered: 1.96
7. Landowner(s) of Record (use blank page to list additional owners):
Abbey Crossing, LLC
Name Name
PO Box 395
Current Mailing Address Current Mailing Address
Jamestown, NC 27282
City, State, Zip City, State, Zip
366-454-6134
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 8456 _ Page 173-177
Book Page _
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PART B.
Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
Abbey C
Name
P Box395
Current Mailing Address
Jamestown, NC 27282
City, State, Zip
336-454-6134
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Signature
Printed Name
Mailing Address
Telephone Number
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.
C. Craig Stone _Member
Type or Print am Title of Authority
_ APe4k- 12- = 2aZZ _
Signature Date
I, �� AVtS RAI`( a Notary Public of the County of _ la�It.�oR-J� State of North
Carolina, do hereby certify that C. • O R' Au 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 I Z'W day of A,pQ« , 20 z 2-
�o NQTARY
o�
P!lBLIC ��
���If11111i►11t1�1
R
Notary Public
My commission expires: p9_Lc_ ("] , 2OZ3
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