NCC223903_FRO Submitted_20221129

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 N/A in the blank.)
Part A.
1. Project Name Abby Meadows
2. Location of land -disturbing activity: City or Township Clayton Township
Highway/Street Barber Mill Rd Latitude 35.59079 Longitude-78.48538
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.14
6. Amount of fee enclosed: $ 4,300 . The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 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__
10
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nathan Evans E-mail [e-mail]
Telephone [phone] cell # N/A Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
Cloudbreak Investments, LLC 919-345-6729 N/A
Name Telephone Fax Number
PO Box 189 1130 Situs Court Suite 244
Current Mailing Address Current Street Address
Clayton NC 27528 Raleigh NC 27606
City State Zip City State Zip
Deed Book No. 06171 Page No. 0250
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):
Cloudbreak Investments, LLC [e-mail]
Name E-mail Address
PO Box 189 1130 Situs Court Suite 244
Current Mailing Address Current Street Address
Clayton NC 27528 Raleigh NC 27606
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A NSA N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A _ N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A NSA N/A N/A N/A
City State Zip City ^ State Zip
Telephone N/A Fax Number N/A
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 i f rmat.on should there be any change in the information provided herein.
�,.;, a han vans , /L-_ Managing Member
Type or print name Title or Authority
Signat re Date
I, _ C5 I �Ct ICJ _ (n3 a Notary Public of the County of f
State of North Carolina, hereby certify that _�i�e n �(G� (�S 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 ) -day of 20
i HoNo RftPAAdbajms Notary
Jest C dine
M Com s1a�r�i ID"tl -Zb My commission expires