NCC216165_FRO Submitted_20211129

JOHNSTON COUNTY 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 before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Johnston County Department of Public Utilities. (Please type or print and, if the question is not applicable or
the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Beverly Lots 12,18,19,20,21,22,23,24,25,26,29,30,32,33,34,35,38
2. Location of land -disturbing activity: City or Township Elevation Township
Highway/Street Reedy Creek Rd Latitude 3S, 50ZbQ t Longitude " 181 S t8i9 j
3. Approximate date land -disturbing activity will commence: >*-r%EV:1A;*
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.94
6. Amount of fee enclosed: $ 3630.00 . The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 per acre for each
additional acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
741
10.
Name_J'C& %A C.LaWE S E-mail Address 3CLOL-tSP JAAV;XGA FFcl+ESLLC. CoOA
Telephone R 6 -CAA -040 Cell # Ct III - 609 - (o 3% Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
DrV20scrA RCH&S (.c I c9 - 31 co- CO3B(CR
Name Telephone Fax Number
11-1 C.E.r "Loj ; c r S A t% C
Current Mailing Address Current Street Address
C kzJ dC 21S13 _
City State Zip City
Deed Book No. Ict 0 Page No, 1 3 O — M
Part B.
State
Zip
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
DAv3;0Sa&-"� trkot^-� LLC
Name
in CEr P*toer. CT
Current Mailing Address
E-mail Address
Current Street Address
C AH I-k- 27SI 3 _
City I State Zip City
Telephone 9 t9 - 3-1L' (C' M Fax Number,
State
Zip

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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
RM0 t-'ELsori
TypeM print name
Signs ure
Lwoi5=00 9"SSaF..'�-
Title or Authority
112- 2�
Date
------(---------------------- --- --
I, a Notary Public of the Countyof
In
State of North Carolina, hereby certify that Vc-ul appeared
personally before me this day and being duty sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �[ day of �Jt V 120
F____ ___ ;L=
JAIRO ARIAS-RAREJA
Notary
NOT;GPl Bt L NORTH CAROLINA
KE COUNTY My commission expires
Me Corr, t sti c:n EK • ics Ocr ? i. 2t�21