NCC215978_FRO Submitted_20211029

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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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 N/A in the blank.)
Part A.
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1. Project Name '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): 13.85
6. Has an erosion and sediment control plan been filed? Yes No Enclosed X
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Lipscomb E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
8. Landowner(s) of Record (attach accompanied page to list additional owners):
J & B Real Estate Consultants, LLC 919-323-3720 N/A
Name Telephone Fax Number
328 E Main Street 328 E Main Street
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
9. Deed Book No. 05388, 05748 Page No. 0816, 0448 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.) If the company orfirm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
J & B Real Estate Consultants, LLC [e-mail]
Name
328 N Main Street
E-mail Address
328 E Main Street
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State
Telephone [phone]
Zip City
Fax Number
N/A
State
Zip

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
Name
NIA
Current Mailing Address
NIA NIA NIA
City State Zip
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA NIA NIA
City State Zip
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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
E-mail Address
NIA
Current Street Address
NIA NIA NIA NIA NIA NIA
City State Zip City State Zip
Telephone
NIA
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
Signature
Manager
Title or Authority
12'e;2L.
Date
I, a Notary Public of the County of dc�tlw
State of North Carolina, hereby certify that IAJUVLi;.S L( 9,�r`61-1'�'b appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hartCiand+nparial seal, this day of J GV , 20 4
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c. teu B L,G Zv My commission expires
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