NCC215650_FRO Submitted_20211014

.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 NIA in the blank )
Part A. I rr-/I
1. Project Name NAWrV0JW& WErT Sumit/15tay
0' 2 Location of land -disturbing activity: City o Township JUJ�LS
Highway/Street u% VW11 39 Latitude 55. 782 30 Longitude - 70.1-7270
3. Approximate date land -disturbing activity will commence: LIPOAI RE &P'l OF P641 M1T
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ZE6IDEJJnAL.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27. 40
6 Amount of fee enclosed. $ rY 28U. 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed ✓
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name .BRAD 6,0JlZZ-0A1 E-mail Address ieah 5959 /0 a0/. corn
Telephone) 553 - 7904 Cell # 0 9) 47-7- 3736 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
1 EusJ✓ ProP,l:JzyY bJ:. gzpnlEt1f L14(919 ) 3b9 - 6511 u 1A
Name
Telephone F x Number
174 Tvw,isaib -bmyE.
179 7oswyasEwn bjnvE.
Current Mailing Address
Current Street Address
C'LAVI' / Alt 27527
& AY:WA1 JUG 27527
City State Zip
City State Zip
10. need Book No. 05816 Page No.
0001
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):
TQGY [EX-. Co.05
nousebyg o ad corn
Name
E-mail Address
179 75-wxi6wJ5 -D z,ys
179 7 wvsgjib -bovE.
Current Mailing Address
Current Street Address
CLAVI.-W 0c, 2752.7
LLAYTod A1G 27527
City State Zip
City State Zip
Telephone {/ 919) 3b9 - (cr71j
/
Fax Number N /,Q

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
u 1A Iv 1A
N e E-fnail Address
u A u 1A
CLIrrent Mailing Address Cu rent Street Address
MIA w�A
Cit State Zip Ci State Zip
Telephone N / A Fax Number 9 1 1A
(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:
A 9 / A
Nafne of Registered Agent E- ail Address
A N 1A
Cu rent Mailing Address Cu rent Street Address
�A
City
State Zip
M JA
City State Zip
Telephone M A 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.
RACY i_F�_ CoArs
Type or print name Title or Authority
&—tz� ciJli
Signature Date
41�1�3 a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being dui warn acknowledged that the above form was
executed by hire.
Witness my hand and notarial seal, this o? i day of 20
0,1,1Z 13
Not
Seal
My commission expires yY)yy0-)
JENNIFER BAKER
Notary Public, North Carolina
Johnston County
My Commission Expires