NCC242647_FRO Submitted_20240830

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 Penn Burlington
2. Location of land-disturbing activity: County Alamance City or Township Burlington
Highway/Street Rural Retreat Road (SR-! Latitude 36d 4' 14.3904"N Longitude 79d 31' 16.2876"W _
3. Approximate date land-disturbing activity will commence:8/1/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.18 acres
6. Amount of fee enclosed: $225 . The application fee is $225 for disturbed areas
between 1.0 and 2.0 acres, plus an additional $100 per acre (rounded up to the next acre) is assessed
without a ceiling amount(Example: a 9-acre application fee is$925).
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 Will Stevens E-mail Address willapennres.com
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
3500 S Clark St 3500 S Clark St
Current Mailing Address Current Street Address
Arlington VA.22202
City State Zip City State Zip
10. Deed Book No.3701 Page No.394 Provide a copy of the most current deed.
11. Tax Map No. 3 Block 26 Lot No. 134
12. Parcel ID 174269 GPIN (State ID)8844558174
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):
w:lie pev►✓ireS .loH"
Name E-mail Addre s
35c o <<.,,,d e-• i (1s C t- 54 ..e
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 336 SiSt7.S97-7 Fax Number t he

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:
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.
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Signature Date
I \„;otktir Ci- DC-G CC a Notary Public of the County of G-u,\c' _
State of North Carolina, hereby certify that W�k\,)Geo P V ed S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. t '
Witness my hand and notarial seal, this I day of !"_ J , 20 a va"i
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