NCC221699_FRO Submitted_20220503

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 b this the Cit orm d an acceptable
c Burlington's
erosion and sedimentation control plan have been completed and approvedY Y
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)
Part A.
1. Project Name Apple Ridge Subdivision
Alamance Cit or Township Burlington
2. Location of land -disturbing activity: County Y _79.421568
Highway/Street Apple Street Latitude 36.105988 Longitude
3. Appr
oximate date land -disturbing activity will commence: Upon Permitting 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.1 Acres
6. Amount of fee enclosed: $ 645.00 . 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). X
7. Has an erosion and sediment control plan been filed? Yes No
X Enclosed
8. Person to contact should erosion and sediment control issues arise during
land-disturbing
an dlberlsouthtnet.
Name Pastor Greg Hargrave E-mail Address 9 g @
Telephone [phone] Cell #
336-214-0537 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners): n/a
Curry Hayes Homes, Inc. 336-214-0537
Name
Telephone Fax Number
421 Fulton Street 421 Fulton Street
Current Mailing Address Current Street Address
Burlington, NC 27217 Burlington, NC 27217
City
State Zip City State Zip
10. Deed Book No. 4018 Page No. 304 Provide a copy of the most current deed.
11. Tax Map No.
12-55A-24 Block Lot No.
12. Parcel ID 138417 GPIN (State ID) 8875575710
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):
Curry Hayes Homes, Inc. [e-mail]
Name E-mail Address
421 Fulton Street 421 Fulton Street
Current Mailing Address Current Street Address
Burlington, NC 27217 Burlington, NC 27217
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
Name
Current Mailing Address
E-mail 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:
n/a
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 intheinformation provided herein.
Typ�na
Title or Authority
-2_0 2
Signatu Date
a.wr• J
C J 0 J, S a Notary Public of the County of a �-
State of North Carolina, hereby certify that
altll(J appeared
personally before me this day and being dul sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,
No d. �kP
MY
COMMISSION EXPIRES
UBUG ?0
this day of*'4Ad_1 20 a'
Abta'
My commission expires "O`er