NCC230363_FRO Submitted_20230208

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA 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 THE WILLOWS @ BURLINGTON
2. Location of land -disturbing activity: County ALAMANCE City Or TOWRShIp BURLINGTON
Highway/StreetST MARKS CHURCH RDLatitude 36.071429 Longitude-79.515459
3. Approximate date land -disturbing activity will commence: 1-1--2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.46 AC
6. Amount of fee enclosed: $ 585.00 for 8 AC . 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 TIM HESS E-mail Address [e-mail]
Telephone [phone] Cell# (919)-349-0174 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WILLOWS BURLINGTON, LP (704)-609--0682
Name Telephone
Fax Number
13860 BALLANTYNE CORPORATE PL, #175 1480 SAINT MARKS CHURCH RD
Current Mailing Address
CHARLOTTE, NC 28277
City State
10. Deed Book No. 070
11. Tax Map No.
12. Parcel ID 0673539
Zip
Current Street Address
BURLINGTON, NC 27215
City State
Zip
Page No. 0067 Provide a copy of the most current deed.
Block Lot No.
GPIN (State ID) 8844-75-7040
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):
THE WILLOWS BURLINGTON, LP [e-mail]
Name
E-mail Address
13860 BALLANTYNE CORPORATE PL, *175 13860 BALLANTYNE CORPORATE PL, #175
Current Mailing Address Current Street Address
CHARLOTTEE, NC 28277 CHARLOTTEE, NC 28277
City State Zip City State
Telephone [phone] Fax Number
M.

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 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:
DAVID RANSENBERG
Name of Registered Agent
13860 BALLANTYNE CORPORATE PL, #175
Current Mailing Address
CHARLOTTE, NC 28277
City
State Zip
[e-mail]
E-mail Address
13860 BALLANTYNE CORPORATE PL, #k175
Current Street Address
CHARLOTTE, NC 28277
City State Zip
Telephone [phone] 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.
DAVID RANSENBERG
Type or print name
PRESIDENT (WILLOWS BURLINGTON, LP)
Title or Authority
11-22-22
Date
I, I15V� ar ' i) . rs V'CI-c"Uq L , a Notary Public of the County of ldIn i z m
State of North Carolina, hereby certify that (� a V I A 94--vi S6VA hL�:� 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 �,`�ay of 00 UI­ 20 d� �-
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