NCC222174_FRO Submitted_20220701

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 N/A 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 The Stables at Harris Farm Phase 2
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Alamance Road Latitude 36.06154 Longitude-79.47413
3. Approximate date land -disturbing activity will commence. JUNE 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.07 ACRES
6. Amount of fee enclosed: $ 405 . 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 Will Derrickson E-mail Address wderricksonuncgo.com
Telephone [phone] Cell # . 336-979-4054 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)-
Clayton Properties Group, Inc. (DBA Shuart Homes) 336-765-9661
Name Telephone Fax Number
221 Jonestown Road 5000 Clayton Road
Current Mailing Address Current Street Address
Winston-Salem NC 27104 Maryville TN 37804
City State Zip City State Zip
10. Deed Book No. 4041 Page No. 36 Provide a copy of the most current deed.
11. Tax Map No. 12 Block 4 Lot No. 11A
12. Parcel ID P/O 114544 GPIN (State ID) P/O 8854918118
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):
Clayton Properties Group, Inc. (DBA Shugart Homes) [e-mail]
Name E-mail Address
221 Jonestown Road 221 Jonestown Road
Current Mailing Address Current Street Address
Winston-Salem NC 27104 Winston-Salem NC 27104
City State Zip City State Zip
Telephone [phone] Fax Number 336-765-1295

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
urrent Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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
Telephone
State
E-mail Address
Current Street Address
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.
Chris RR "inet Vice President/Market Manager
Tr66r��t-
Title or Authority
- !,47- it-ZZ
nature— Date
a Notary Public of the County of 02 V I d- Lck-r
State of North Carolina, hereby certify that a ►'1i5 J-n Ct6yilf � 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
CONNIE A. ADER
Nd"Y PUBLIC
Davidson County
North Carolina
My Commission Expires 04/05/2025
day of / / I 20��
Notary I
My commission expires/ v!?�