NCC221102_FRO Submitted_20220318

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place NIA in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
►.
3
4
5
6
Project Name McDONALD'S
Location of land -disturbing activity: County ALAMANCE City or Township BURLINGTON
Highway/Street 1829 N. CHURCH ST. Latitude 36.094998 Longitude-79.406771
Approximate date land -disturbing activity will commence: JANUARY 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERICAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.65
Amount of fee enclosed: $ $225.00 . The application fee of $225 for the initial 2 acres
plus $60 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $645).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_
8
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Leo Van Buuren E-mail Address [e-mail]
Telephone [phone] Cell # 919-931-2845 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
McDonald's Real Estate Company
Name Telephone
10.
110 N Carpenter Street
Current Mailing Address
Chicago IL 60607
City State Zip
Deed Book No. 451
11. Tax Map No. 140-567-144
12, Parcel ID 139743
Page No._
Bloc
Current Street Address
City
221
State
Fax Number
WE
Provide a copy of the most current deed.
GP1N (State ID)
Lot No. _
8875938657
Part B.
1. Person(s) or firm($) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
LLG
Name
U IV G 4
Current Mailing Address
City State Zip
Telephone 1— 6 3D ­603 -3,5' �
E-mail Address
Current Street Address
City State
Fax Number
Zip

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
C4Q ZA- AViv,6�7— 02.
Current Mailing Address
F4, --AA0L A/,C. 7
City State Zip
Telephone
L Ed . ✓ A- 4A JI _ fu •i
E-mail Address
Current Street Address
J4-A..t
City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation• give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
C ity
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax 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 his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority
Z_
Signature Date
I, lh a Notary Public of the County of
State of North Carolina, hereby certify that L J 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 10+�Lday of w 20
Seal
JUSTIN A LIVELY
Notary Public
Pitt Co.,_North Carolina
My Commission Expires May fi, 2024
N ry
My commission expires_