NCC222426_FRO Submitted_20220725

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (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 Clayton 42
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street NC HWY 42 Latitude 35.638 Longitude-78.441
3. Approximate date land -disturbing activity will commence:
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Mass Grading
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.95 aC
6. Has an erosion and sediment control plan been filed? Yes No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Wes Reynolds E-mail [e-mail]
Telephone [phone] Cell # 919-754-7645 Fax # [phone]
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton 42 Investments, LLC 919-754-7645 919-420-7807
4
Name
4004 NC 55 Hwy Ste 100
Current Mailing Address
Cary
City
NC 27519
State Zip
Telephone Fax Number
251 NC HWY 42
Current Street Address
Clayton NC 27527
City
Deed Book No. 5372 page No 843
Part B.
State
Zip
Provide a copy of the most current deed.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Clayton 42 Investments, LLC
Name
4004 NC 55 Hwy Ste 100
Current Mailing Address
Cary NC
City
[e-mail]
E-mail Address
4004 NC 55 Hwy Ste 100
Current Street Address
27519 Cary NC
State Zip
Telephone [phone]
27519
City State Zip
Fax Number 919-420-7807

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 E-mail Address
Current Mailing 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. ff 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.
Wes Reynolds Member
Type or print name
Wes Revt old
Signature
Title or Authority
ly signed by As Reynolds
202 ,,09.23 F:58 32 04'00' 9/23/21
a Notary Public of the County of �l
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowleddg d that the above form was executed
by him.
Witness my hand and notarial seal, this_day of 20'
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