NCC224028_FRO Submitted_20221206

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
4M
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 O'Neil Overlook
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street N O'Neil Street Latitude 35.66 Longitude -78.45
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): 13.71
6. Has an erosion and sediment control plan been filed? Yes I✓ No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameNick MCKeel E-mail Address Nick. McKeel@providence. construction
Telephone [phone] Cell # n/a Fax # n/a
8. Landowner(s) of Record (attach accompanied page to list additional owners):
O'Neil Overlook LLC 919-670-0704 n/a
Name Telephone
114 W Main Street
Current Mailing Address
Clayton
Current Street Address
NC 27520 Clayton
City State
9. Deed Book No. 06325
Part B.
Zip City
Page No. 0585
Fax Number
NC 27527
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 ►esponsible party.
O'Neil Overlook LLC
Name
114 W Main Street
Current Mailing Address
Clayton NC 27520
city
State Zip
[e-mail]
E-mail Address
Current Street Address
Clayton NC 27527
city
Telephone [phone] Fax Number n/a
State
Zip

2„ (a) If the Financially Responsible Party rs 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
Telephone
Fax Number
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State
Fax Number
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.
Reid Smith
Managing Member
Type or print name Title or uthorky
dje�t 'gi— — I t fol
Signatur Date
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I, LA K l'�) 1 , a Notary Public of the County of �A-7'0 4
State of North Carolina, hereby certify that E-to 5tL r-rr+ _ 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 ' ` 46M56Z— , 20
CHRIS CAVALIER
NOTARY PUBLIC
Johnston County Notary
rdina
MYCOMM on ices July 2, 2024 �I
My commission expires i