NCC221185_FRO Submitted_20220328

a
FINANCIAL RESPONSIBILITY/OWNERSHIpFORM SEDIMENTATION ont
No person may initiate NRL ACT
any land -disturbing activity that sTurbNonOoTmoe acres as covered
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
Sedimentation control plan have been completed and aown by erosion
Town of
an one
acre that are part of a larger plan of development are also subject to Town of Clayfonof Clayton. sSoilall;rosi�on and
Sedimentation Control Ordinance and are required to corrrptete this Form. (fin of 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 Creekside Commons Phase 6
2. Location of land -disturbing activity. County JQHNSTUN
City or Township CLAYTON
Highway/Street Champion St Latitude 35.3754N
Longitude 7$.2712W
3. Approximate date land -disturbing activity will commence:' 3/27/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 2 Acres
B. Has an erosion and sediment control plan been filed? Yes X
No- Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Beasley E-mail Address [e-mail]
Y @gmail.com
Telephone Cell ## 919 369 205$
Fax #
8. Landowner(s) of Record (attach accompanied page to list additional owners).
Glenwood Horses LLC 919 848 1461
Name Telephone
Fax Number
PO 90427 9220 Fairbanks Dr
Current Mailing Address Current Street Address
Raleigh NC 27675 Raleigh NC NC
City State Zip city State 27613
Zip
9. Deed Book No. 4360 Page No. 680 Provide a copy of the most current deed -
Part S.
1. Company(ies) or firm(s) who are firtancially responsible for the land -disturbing activity (Provide a
Comprehensive I►St of all responsible parties on an attached sheet_) if tho oompany or fret is a sole
Proprietorship the name of .the owner or manager may be listed as the financially responsible party.
Glenwood Homes LLC Mitch Imurphy@gmail_com
Name P-mall Address
PO 90427 9220 Fairbanks Dr
Current Mailing Address Current Street Address
Raleigh NC 27675 Raleigh NC 27613
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:
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_
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 in the information provided herein.
Mitchell T Murphy
type or print name
Managing member
Title or Authority
3/14/2022
Uate
a Notary Public of the County of
State of North Carolina, hereby certify that U, e i f
Personally before me this day and being duly sworn acknowledged that the above form was executed
by hire.
Witness my hand and notarial seal, this —t!�L_day of 20�
=o� �0TAI? Notary
— gas zaz5 —
My commission expires
fy PUBLIC i`[s:
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