HomeMy WebLinkAboutNCC215666_FRO Submitted_20211013JOHNSTON 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 Maggie Way Amenities
2. Location of land -disturbing activity: City or Township WilderS Township
Highway/Street Howards Crossing Drive Latitude 35.738 Longitude 78.378
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.54
6. Amount of fee enclosed: $ 990.00 . The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 per acre for each
additional acre (rounded up to the next acre). 3aC * $330 = $990
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Blackmon E-mail Addresschadpe2@yahoo.com
Telephone (919) 539-3636 cell # (919) 539-3636 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Maggie Way, LLC
(919) 422-4704 N/A
Name
Telephone Fax Number
328 East Main Street
328 East Main Street
Current Mailing Address
Current Street Address
Clayton NC
27520 Clayton NC
27520
City State
Zip City State
Zip
10. Deed Book No. 5324
Page No. 61 1
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):
Maggie Way, LLC
N/A
Name
E-mail Address
328 East Main Street
328 East Main Street
Current Mailing Address
Current Street Address
Clayton NC
27520 Clayton NC
27520
City State
Zip City State
Zip
Telephone (919) 422-4704
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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA NIA NIA
NIA NIA N/A
City State Zip
City State Zip
Telephone N/A
Fax Number NIA
(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:
Jaynes Lipscomb
james@myhtr.com
Name of Registered Agent
E-mail Address
328 East Main Street
328 East Main Street
Current Mailing Address
Current Street Address
Clayton NC 27520
Clayton NC 27520
City State Zip
City State Zip
Telephone (919) 422-4704 Fax Number NIA
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.
James Lipscomb
Type r ame
Signature
Partner
Title or Authority
Date
I, ��'c «;� L C�rE F , a Notary Public of the County of
State of North Carolina, hereby certify that � � S "�S c.6,"-�6 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 Iday of /�/ .v�� 2Q2- i_
Patricia B Creel ._Jr
Notary Public Notary
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