NCC222320_FRO Submitted_20220624

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 1 I3A-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.
2.
3,
4.
5.
6.
Project Name Falls Grove- Residential Construction
Address/Location of land -disturbing activity (include Zip Code)
955 Horneytown Rd., High Point, NC 27265
Latitude (decimal degrees) 36.002 Longitude (decimal degrees) -80.057
Approximate date land -disturbing activity will commence: June 2022
Purpose of development (residential, commercial, industrial, etc.)
Residential
Approximate acreage of land to be disturbed or uncovered: 2.0 acres in closed Lots
7. Has an erosion and sedimentation control plan been fled? Yes x No
Landowner(s) of Record (use blank page to list additional owners):
Pulte Home Company, LLC
Name Name
1225 Crescent Green Dr. STE 250
Current Mailing Address
Cary, NC 27518
City, State, Zip
Telephone Number
Current Mailing Address
City, State, Zip
Telephone Number
9. Indicate book and page where deed or instrument is fled (use blank page to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
Development Book 2445
Pulte Lots Book
Page 0325
Page
FinResFm. Page # 1

PART B.
I. Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
Pulte Home Company LLC
Name Name
1225 Crescent Green Dr. STE 250
Current Mailing Address Current Mailing Address
Cary, NC 27518
City, State, Zip City, State, Zip
336-480-5195
Telephone Number Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Printed Name of Registered Agent Name of Individual to Contact (if
Registered Agent is a company)
Mailing Address Street Address
Email Address 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.
Chris Raughley VP Land Development
Type or PrintNameTitle of Authority
Signature Date
I, V , t i Scj Syffl ee c y-t Gl , a Notary Public of the County of N of k-e- _ , State of North
Carolina, do hereby certify that CIVl V1 S IC�r �} , 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 , �VtV".I_ , 20��,.�`��SA
Notary Public T My commission expires: Z-1 �.•' oTgR� , y'.
FinResFm. P
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