NCC231103_FRO Submitted_20230419

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 Mackintosh on the Lake Parcel I - Section 1-2
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Bonnar Bridge Pkwy Latitude 36.053449 Longitude-79.536977
3. Approximate date land -disturbing activity will commence: 9-1-22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.00 ac.
6. Amount of fee enclosed: $ 405.00 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff White E-mail Address iwhite@_greenhawkcorp.com
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10.
11.
12.
Telephone [phone] Cell # 919-422-5741 Fax # n/a
Landowner(s) of Record (attach accompanied page to list additional owners):
AF-Brooks Creek LLC 919-861-2900 n/a
Name Telephone Fax Number
1300 Sunday Drive 1300 Sunday Drive
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
Deed Book No. 2884 Page No. 0574 Provide a copy of the most current deed.
Tax Map No. 3
Block 23
Lot No. 7
Parcel ID 174146 GPIN (State ID} 8643191320
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):
AF-Brooks Creek, LLC [e-mail]
Name E-mail Address
1300 Sunday Drive 1300 Sunday Drive
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
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 n/a
Name E-mail Address
n/a n/a
Current Mailing Address Current Street Address
n/a
city State Zip
n/a
city
Telephone n/a Fax Number n/a
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:
n/a
Name of Registered Agent
n/a
E-mail Address
n/a n/a
Current Mailing Address Current Street Address
n/a n/a
City State Zip City State Zip
Telephone n/a Fax Number n/a
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.
Chief Operating Officer
Title or Authority
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Date
I, � Olvr (� / 10 0 di , a Notary Public of the County of Wa've_
State of North Carolina, hereby certify that Af 1�° .hi+e - appeared
personally before me this day and being duty sw rn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �,1�day of���, 20
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Notary
Seal : U
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