NCC220845_FRO Submitted_20220315

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 Peyton Place Apartments
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Bonnar Bridge Pkwy. Latitude 36.060 Longitude -79.525
3. Approximate date land -disturbing activity will commence: February/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.58 Ac.
6. Amount of fee enclosed: $ 225.00 . 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 Dennis Euliss E-mail Address [e-mail]
0
Telephone [phone] Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Peyton Place, LLC (336)-350-8090
Name Telephone
524-A W. Elm St. 524-A W. Elm St.
Fax Number
Current Mailing Address
Current Street Address
Graham, NC 27253
Graham, NC 27253
City State
Zip
City State Zip
10. Deed Book No. 4259
Page No.
661 Provide a copy of the most current deed.
11. Tax Map No. 3-23-476
Block Lot No.
12. Parcel ID 106685
GPIN (State ID) 8844417391
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):
Peyton Place, LLC
[e-mail]
Name
E-mail Address
524-A W. Elm St.
524-A W. Elm St.
Current Mailing Address
Current Street Address
Graham, NC 27253
Graham, NC 27253
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 Current Street Address
City State Zip City
Telephone Fax Num
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 Zip
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.
Dennis H. Euliss Registered Agent
Type or print name Title or Authority
ignature Date
a Notary Public of the County of WQr'(1G.f1a,
State of North Carolina, hereby certify that V.wn1 -5 1'1 �.�.IIISS 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 1� day of 20_�)
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