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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 2. Location of land-disturbing activity: City or 3. Approximate date land-disturbing activity will 4. Purpose of development (residential, commercial, industrial, institutional, 5. Total acreage disturbed or uncovered (including off-site borrow and waste 6. Amount of fee enclosed: 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? Enclosed_________ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: E-mail Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book Page Provide a copy of the most current deed. 11. Tax Map No. Lot No. 12. Parcel ID GPIN (State 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): Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Fax ---PAGE BREAK--- 2. 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 Fax 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 Fax 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. Type or print name Title or Authority Signature Date I, a Notary Public of the County of State of North Carolina, hereby certify that appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this of Notary Seal My commission