NCC215523_FRO Submitted_20211005

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Baylee Ridge Phase 1, Lots 1-10, 66-72, 76-98
2. Location of land -disturbing activity: City or Township Johnston County
HighwaylStreet Lynch Road Latitude 35.67689 Longitude-78.32415
3. Approximate date land -disturbing activity will commence: Summer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.84 ac
6. Amount of fee enclosed: $ 3.235.00 . The application fee of $250.00 per acre (rounded
up to the next acre) is assessed for the first 8 acres and an additional $65 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
N Adam Skidmore E '1 Add k;d b Ilk
ame
-ma i ress as i more@ro uc omes.com
Telephone Cell # 919-302-3751 Fax #
9. Landowner(s) of Record (attach accompanied
page to list additional owners):
Creekside Development Partners, LLC
Name
Telephone Fax Number
P.O. Box 17102
6131 Falls of Neuse Road, Suite 200
Current Mailing Address
Current Street Address
Raleigh NC 27619
Raleigh NC 27619
City State Zip
City State Zip
10, Deed Book No. 05287 Page No.
0095
Part B.
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):
Robuck Homes Triangle, LLC c/o Jessica Head
[e-mail]
Name
E-mail Address
P.O. Sox 17102
6131 Falls of Neuse Road, Suite 200
Current Mailing Address
Current Street Address
Raleigh NC 27519
Raleigh NC 27519
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:
NIA
Name
NIA
Current Mailing Address
NIA
City
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City
Fax Number
NIA
State Zip
(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:
NIA NIA
Name of Registered Agent E-mail Address
NIA NIA
Current Mailing Address
NIA
City State
Telephone NIA
Current Street Address
NIA
Zip City
Fax Number NIA
State Zip
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.
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Ty rint name Title or Authority
jrtf( AK L2-02-1
i ture Date
I, ) i r�r•� , a Notary Public of the County of UAk�
State of North Carolina, hereby certify that Je.S l v 1k4d appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand a�,d��dihl��al, this
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D day of 20 ,) i
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