NCC222650_FRO Submitted_20220810

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 Frank Holt Lots
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Frank S Holt Drive Latitude 36.046690 Longitude-79.452408
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Land Clearing
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.92 Acres
6. Amount of fee enclosed: $ 465.00 . 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christopher Powell E-mail Address [e-mail]
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
M & P Developments, Inc. 336-350-9752
Name
1635 Nova Lane
Current Mailing Address
Burlington, NC 27215
City 515 State Zip
10. Deed Book No. 2502 Page No._
Telephone
1635 Nova Lane
Current Street Address
Burlington, NC 27215
State
n/a
Fax Number
Zip
Provide a copy of the most current deed.
11. Tax Map No.12-5A-58, 12-5A-62, 12-5A-63Block Lot No.
12. Parcel ID 120361, 120363, 120365 GPIN (State ID) 8863660122, 8863662197, 8863665276
Part B.
City 750
366
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):
M & P Developments, Inc. [e-mail]
Name E-mail Address
1635 Nova Lane 1635 Nova Lane
Current Mailing Address Current Street Address
Burlington, NC 27215 Burlington, NC 27215
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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:
n/a
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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:
n/a
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
l�"m'�<_L C. P�,eLL 6��. ,
Type or rint name Title or Authority
Signature Date
l.f a Notary Public of the County of 9
G
State of North Carolina, hereby certify that �WA,V/,Ld G - YS&qZ1 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 y 20 2 2--
LISICHELY COLON CRUZ 4ryvd
NOTARY PUBLIC
AlaW County
No arolina My Commission Expires March 10, 2023 My commission expires2i/% ��
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