NCC215970_FRO Submitted_20211027

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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 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. (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 Winston Pointe South Phase 313
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/street Winston Road Latitude 35.64144 Longitude-78.50933
I Approximate date land -disturbing activity will commence: 5/1 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 39.8
6. Amount of fee enclosed: $ 4, 975 . [The fee of $125 per acre (rounded up to the next
acre) is assessed without a ceiling amount; Single Family lot - $75]
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 Michael Stewart E-mail [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stone Street Builders, LLC 919-779-8649
Name Telephone Fax Number
319 Chapanoke Road
Current Mailing Address Current Street Address
Raleigh NC 27603
City State Zip City State Zip
10. Deed Book No. 5306 Page No 404 Provide a copy of the most current deed.
Part B.
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.) lfthe company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Stone Street Builders, LLC [e-mail]
Name E-mail Address
319 Chapanoke Road
Current Mailing Address Current Street Address
Raleigh NC 27603
City State Zip City State Zip
Telephone [phone] Fax !Number

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:
Name
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
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 Dame. 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 State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
AALtO S:A65 Q aor-
Type or print name Title or A thority
—
Sature Date .411
a Notary Public of the County of
State of North Carolina, hereby certify that `��acknowledg
. f I , appeared
personally before me this day and being duEy swoe th�thea`boveform was executed
by him.
Witness my hand and notarial seal, this'day of CC. 0 _
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