NCC243238_FRO Submitted_20241021

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 Starbucks @ 2405 S Church St
2. Location of land-disturbing activity: County Alamance City or Township Burlington
Highway/Street S Church St Latitude N 36° 04' 50" Longitude W 79° 28' 30"
3. Approximate date land-disturbing activity will commence: 11-04-2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.13 ac
6. Amount of fee enclosed: $ 285 . 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lee Utke E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lemonade MM Burlington LLC
Name Telephone Fax Number
100 High St, Suite 410 Same as Mailing
Current Mailing Address Current Street Address
Boston MA 02110
City State Zip City State Zip
10. Deed Book No. 4373 Page No. 185 Provide a copy of the most current deed.
11. Tax Map No. Block Lot No.
12. Parcel ID 114732 & 114753 GPIN (State ID) 8854983636 & 8854992150
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):
Lemonade MM Burlington LLC ([e-mail]
Name E-mail Address
100 High St, Suite 410 Same as Mailing
Current Mailing Address Current Street Address
Boston MA 02110
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System ct-statecommunicationsAwolterskluwer.com
Name E-mail Address
160 Mine Lake Ct Ste 200 160 Mine I akP Ct Stt 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone[phone] 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:
The Corporation Trust Company ct-statecommunications©wolterskluwer.corn
Name of Registered Agent E-mail Address
1209 Orange St, 1209 Orange St
Current Mailing Address Current Street Address
Wilmington, DE 19801 Wilmington. DE 19801
City State Zip 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.
Lindsey King
n Vice President
Type or p int name Title or Authority
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SiI aturer Date I
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�u,�I, / G` katS , a Notary Public of the County of i leS6
State of jatTUTiffa, hereby certify that L Lnds-e K •
1a1 appeared
personally before me this day and being duly sworn ack�wledged—that the above form was
executed by him. C,
Witness my hand and notarial seal, this v,- day of.X P-/Cm6w'' , 20 c -li
c� LISA EDN/ARDS � to�'"�, Notary Public , ry
i Massachusetts
_ d . My Commission Expires ( My commission expires 2/ab6
,, Mar 10, 2028