NCC223343_FRO Submitted_20220929

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 NIA in the blank.)
Part A.
1. Project Name COPPER RIDGE 5U9DIV1510N
2. Location of land -disturbing activity: County 5TRN1,y City or Township N/A
Highway/Street Nelson Mountain Latitude 35.3703 Longitude-860.2646
3. Approximate date land -disturbing activity will commence: Hugust T, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIHL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.95
6. Amount of fee enclosed: $ 7 000 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes X No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 705EP14 6ORLESON E-mail Address Joseph6urleson@Notmall•com
Telephone 704.9&2 -&975 ext- 30 Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
6urleson Development Group, QC
Name
24& Market Street
Current Mailing Address
Locust NC 28097
City State Zip
7� 0g) 962-&975 ext • 30
Telephone Fax Number
Current Street Address
City
State
Zip
10. Deed Book No. 7769 Page No. 765 & &97 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.
Burleson_ Develop2nent Group. LLC oseph6urlesongNo_tmarl•com
Name E-mail Address
248 Market 5treet
Current Mailing Address Current Street Address
Locust NC 28097
City
State Zip City
State
Zip

Telephone [phone] ext• 30 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:
N/A
Name E-mail Address
N/A N/Fi
Current Mailing Address
N/A
City
Current Street Address
N/A
State Zip City
Telephone N/A Fax Number N/H
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:
Joseph L• Burleson
Name of Registered Agent
2q8 Market 5treet
Current Mailing Address
Locust NC 28097
City State Zip
Telephonej7O4) 982-8975 ext• 30
JosephSurleson@1-fotmarl • com
E-mail Address
Current Street Address
City State Zip
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.
Joseph Burleson _ _ Manager
Type or print name Title or Authority
4-11 G . 11- zaxt
Signatffre Date
a Notary Public of the County of� 1
State of North Carolina, hereby certify that r- ll,tT S c:,n _ 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
day of LLA 20
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