NCC221471_FRO Submitted_20220414

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 Darrowby Ridge
2. Location of land -disturbing activity: County Alamance City or Township Burlington ETA
Highway/Street Bonnar Bridge Pkwy Latitude 36.o6o8oN Longitude 79.5164 W
3. Approximate date land -disturbing activity will commence: April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 34.2 Acres
6. Amount of fee enclosed: $ 2,205.00 . 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 Clay Mize E-mail Address [e-mail]
Telephone [phone] Cell # 336.971.3574 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LeoTerra Development, Inc. 336.279.7280
Name Telephone Fax Number
110 Shields Road 110 Shields Road
Current Mailing Address Current Street Address
Kernersville, NC 27284 Kernersville, NC 27284
City State Zip City State Zip
10. Deed Book No. 3837 Page No. 0877 _ Provide a copy of the most current deed.
11. Tax Map No. Block Lot No.
12. Parcel ID 107041 & 106949 GPIN (State ID) 8844813210 & 8844705965
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):
LeoTerra Development, Inc.
Name
110 Shields Road
Current Mailing Address
Kernersville, NC 27284
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
110 Shields Road
Current Street Address
Kernersville, NC 27284
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
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
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 State Zip
Telephone
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.
�s�o L pns Ma�aGer
Ty or i t na Title or A ority
3�N )aoaa
Wgnitue Date
I, RCb T 46 �Un�et a Notary Public of the County of aal en Ur
State of North Carolina, hereby certify that C r%s`Op�er LyOhS 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 M,oxclk 20 real
Seal p Notary Public Mtn
Mecklenburg 9
County =
My Comm. Exp. _
08-26-2023 Q \
R=t
Notary
My commission expires V946L,10113