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HomeMy WebLinkAboutNCC216706_FRO Submitted_20211228FINANCIAL 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_ (336) 516-5048 Cell # (336) 516-5048 Fax # Landowner(s) of Record (attach accompanied page to list additional owners): Legacy the Park of Burlington, LLC (336) 516-5048 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 (336) 516-5048 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` . iSAAF?" BROWNING c -