NCC231325_FRO Submitted_20230509

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 NW 13 Phase 2
2. Location of land-disturbing activity: City or Township Flowers Plantation
Highway/Street E. Neuse River Parkway Latitude 35.6638 N Longitude 78.3687 W
3. Approximate date land-disturbing activity will commence: Current
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 52
6. Amount of fee enclosed: $ 150.00 . 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). (FRO Transfer for JC#19-024-P)
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andrew Stocks E-mail Address astocks(a�stocksengineerinq.com
Telephone [phone] Cell # 252.450.5140 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KL Flowers Plantation LLC 1.678.751.8535 252-459-8197
Name Telephone Fax Number
105 NE 1st St. SAME
Current Mailing Address Current Street Address
Delray Beach FL 33444-3807 SAME
City State Zip City State Zip
10. Deed Book No. 05675 Page No. 0101
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):
KL Flowers Plantation LLC 1.678.751.8535 252-459-8197
Name Telephone Fax Number
105 NE 1st St. SAME
Current Mailing Address Current Street Address
Delray Beach FL 33444-3807 SAME
City State Zip City State Zip
Telephone [phone] Fax Number 252.459.8197

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:
Patrick Bell or Thomas Turner pbell@kolter. com tturner@kolter. com
Name E-mail Address
2626 Glenwood Ave . Ste 550 2626 Glenwood Ave . Ste 550
Current Mailing Address Current Street Address
Raleigh NC 27856 Raleigh NC 27856
City State Zip City State Zip
Telephone 1 . 919 . 618 . 6295, Fax Number
1 . 4 4 3 . 6 9 9 . 0 1 1 7
(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:
KL Flowers Plantation LLC 1.678.751.8535 252-459-8197
Name Telephone Fax Number
105 NE 1st St. SAME
Current Mailing Address Current Street Address
Delray Beach FL 33444-3807 SAME
City State Zip City State Zip
Telephone [phone] Fax Number 252.459.8197
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.
TO-W)es 1-44 -Y 2 y � � �;z><� S iq n�.�a ry
Type or pri ame Title or Authority V /
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Signa_ure Date
I, .192Ya✓/. (-6407t. , a Notary Public of the County of ttsaotou
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State of i areiina, hereby certify that ,�mrs , �/Aa-✓£y 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 2-, day of MPI/L , 20 2-5
Nota
eito 004, Notary Public State of Florida
Bryon T LoPreste My commission expires m c-b?• ty
AP•_. ,ao� My Commission GG 919288
P�y6�d� l;xgs 01I27/2024
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