NCC221148_FRO Submitted_20220328

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.
2.
3.
4.
5.
6.
7.
8.
Shame Road
Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street
Sharpe Road Latitude 36.116236 Longitude -79.437829
Approximate date land -disturbing activity will commence: Upon Permitting
Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.35 acres
Amount of fee enclosed: $ 1,125.00 . 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).
X
Has an erosion and sediment control plan been filed? Yes No X Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
y Name
Michael Praylor E-mail Address [e-mail]
Telephone
336-471-8987 Cell # 336-471-8987 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Praylor Construction Company, Inc. 336-471-8987 n/a
Name Telephone Fax Number
4005 Pond Valley Court 4005 Pond Valley Court
Current Mailing Address
Current Street Address
McLeansville, NC 27301
McLeansville, NC 27301
City State Zip
City State Zip
10. Deed Book No. 4188 Page No.
776 Provide a copy of the most current deed.
11. Tax Map No. 12-49-160, 12-49-161 Block Lot No.
12. Parcel ID 139946, 139947
GPIN (State ID) 8876017227, 8876018619
Part B.
1. Person(s) or firm(s) who is financially
responsible for the land -disturbing activity (Provide a
list of all responsible parties
on an attached sheet):
comprehensive
Praylor Construction Company, Inc.
[e-mail]
Name
E-mail Address
4005 Pond Valley Court
4005 Pond Valley Court
Current Mailing Address
Current Street Address
McLeansville, NC 27301
McLeansville, NC 27301
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 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:
n/a
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.
a
or
ignature
A
Ti e or Authory� y
I/U/�- -
Date
a Notary Public of the County of
State of North Carolina, hereby certify that �'1 L P�,r 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 in �Lf , 20 22�
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