NCC222154_FRO Submitted_20220620

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.
1. Project Name Dunkin' Donuts
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street 2604 Maple Ave. Latitude 36.061 ON Longitude-79,4330 W
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.13
6. Amount of fee enclosed: $ 225 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Curtis Little - MOC Maple Ave, LLC E-mail Address [e-mail]
Telephone [phone] Cell # 843-906-0882 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MOC Maple Ave LLC 843-906-0882
Name Telephone Fax Number
500 6th Street Same as mailing address
Current Mailing Address Current Street Address
San Antonio TX 78215
City State Zip City State Zip
10. Deed Book No. 4322 Page No. 540 & 543 Provide a copy of the most current deed.
11. Tax Map No. 6-6-516-6-6, & 6-6-4 Block Lot No.
12. Parcel ID 132511, 132512, 132515 GPIN (State ID) 8874211456,8874212368,8874211323
Part B.
1. Person(s) or firm(s) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Curtis Little [e-mail]
Name E-mail Address
500 6th Street Same as mailing address
Current Mailing Address Current Street Address
San Antonio TX 78215
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Northwest Registered Agent Service, Inc.
Name
4040 Wake Forest Road, Suite 349
Current Mailing Address
Raleigh NC
City State
Telephone [phone]
[e-mail]
E-maildress
Same as Failing Address
Current Street Address
27609
Zip City
Fax Number
State Zip
(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
City State Zip
Telephone
E-mail Address
Current Street Address
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.
Curtis Little - Mount Oak Capital
Type or print name
��Y '
Signature
Managing Partner
Title or Authority
zap
Date
I, [, /ltc r _ _cac �°. �r= , a Notary Public of the County of L)61 _+o t-
State of Nladh Carolina, hereby certify that ~ appeared
personally before me this day and being duly sworn acknowledged that the above fora was
executed by him.
Witness my f"itarial seal this
fj.✓
€" day of 20 '�
N� . ..
Notary
r�rs._1,
5' P/ �~
My commission expires