NCC216706_FRO Submitted_20211228

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 before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the blank.)
Part A.
Project Name Legacy the Park Apartments
2. Location of land -disturbing activity: County Alamance City or Township: Burlington
Highway/Street Tucker Street
Latitude_36004'44"N, _ Longitude_79026'23"W
3. Approximate date land -disturbing activity will commence: December, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Residentiai�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.86 Acres
6. Amount of fee enclosed: $ 1,245 . The application fee of $225 for the first two acres and
$60.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $585).
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 Jason DeBoer E-mail Address iWiLgpL@_yahoo.com
Telephone_ [phone] Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Legacy the Park of Burlington, LLC [phone]
Name Telephone
PO Box 767
Current Mailing Address
Burlington NC 27216
City State Zip
2772 Alamance Road
Current Street Address
Fax Number
Burlington NC 27216
City State Zip
10. Deed Book No. 4229 Page No. 368 - 370 Provide a copy of the most current deed.
Part B.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Legacy the Park of -Burlington, LLC ildeboer ahoo.com
Name E-mail Address
PO Box 767 2772 Alamance Road
Current Mailing Address Current Street Address
Burlington, NC 27216 Burlington, NC 27216
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:
Name E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip 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
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
Jason DeBoer
Type or print name
Si Lure
Member 1 Manager
Title or Authority
11 /30121
Date
a Notary Public of the County of
f
State of North Carolina, hereby certify that _Jason DeBoer appeared personally
before me thiwday and being duly sworn acknowledged that the above form was executed by him -
Witness my hand and notarial seal, this day of 20,121
9
..,. Notary
"4 S�peal OFFICIAL SEAL
tr�ry Dublin, North Carolina
::aunty oY Atamance My commission expires` .
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