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HomeMy WebLinkAboutNCC243238_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 Iutke@roseview.com Telephone 407-421-1633 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 (king@roseview.com 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 617-272-0267 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(855) 316-8944 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 (800) 677-3394 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 , a z 1 SiI aturer Date I I. T , l 1 �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