NCC216245_FRO Submitted_20211110

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 963 Kirkpatrick Rd
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Kirkpatrick Drive Latitude 36.064551 Longitude -79.498879
3. Approximate date land -disturbing activity will commence: November/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial/Office
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.85 Ac.
6. Amount of fee enclosed: $ 285.00 . 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Porterfield E-mail Address [e-mail]
9
Telephone [phone] Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Montgomery Assets LLC (336)-227-6585
Name Telephone
P.O. Box 877 2004 Anthony Rd, Suite B
Current Mailing Address
Graham, NC 27253
Current Street Address
Burlington, NC 27215
Fax Number
City State Zip City State Zip
10. Deed Book No. 4112 Page No. 592 Provide a copy of the most current deed.
11. Tax Map No. 3-22-25; 3-22-26; Block 3-22-27; 3-22-28 Lot No.
12. Parcel ID # 112773; # 112772; GPIN (State ID) 8854224836; 8854224795;
# 112776; # 112775; 8854225647; 8854225589
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):
Montgomery Assets LLC [e-mail]
Name
P.O. Box 877
Current Mailing Address
Graham, NC 27253
City State Zip
Telephone [phone]
E-mail Address
2004 Anthony Rd, Suite B
Current Street Address
Burlington, NC 27215
City State Zip
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Rebecca J. Porterfield Manager
Types �L"_
orprint name Title or Authority
Signature Date I '—
1, �� Ot.A C, cru k 2 , a Notary Public of the County of � LA.; JA rA
State of North Carolina, hereby certify that 'e,be,CCCL -:5. QQ1( W� i e (d 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 6 day of OCA�Obe.+r- 20 t
�Nfl7Karla Grump t/"' l.lL__fJ�-� l../ W
AF1Y PUBLIC
Guilford County, NO
My Commission Expires May 21, 2022 Notary
Seal � n
My commission expires I r lct,