NCC215988_FRO Submitted_20211117

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any lard -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
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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 Titan's Plumbing Storage
2 Location of land -disturbing activity: County Harnett City or Township Averasboro Townsh
Highway/Street S Clinton Avenue (US Hwy 301) Latitude N 35.2959' Longitude W-78.6172°
3. Approximate date land -disturbing activity will commence, October 2021
4. Purpose of development (residential, commercia€, industrial, institutional etc.)' Lt Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2 32 Acres
6. Amount of fee enclosed: $195,00 Normal + $750.00 Express The Express Permitting application fee is a
dual charge. The normal fee of $65 00 per acre (rounded up to the next acre) is assessed without a
ceiling amount. In addition, the Express Permitting supplement is $250 00 per acre up to eight acres,
after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is
$2, 585)
Has an erosion and sediment control plan been filed? Yes No Enclosed XXX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Leanna Hair E-mail Address leannahair(abonsitehomesnc com
Telephone [phone] Cell # Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners)
Mencia Investments, L
Name
36 Sunnyfield Court
Current Mailing Address
919-902-0990
Telephone
Same
Current Street Address
Benson NC 27504 San
City State Zip City
Fax Number
State Zip
10, Deed Book No _ 4013 Page No. 552 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 or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party_
Onsite Homes, LLC ned'ohnson(aonsitehomesnc.com
Name E-mail Address
2931 Breezewood Avenue, Suite 202
Current Mailing Address
FayettevilleNC 28303
City State Zip
Telephone [phone]
Same
Current Street Address
Same
City State Zip
Fax Number 910-483-5195

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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation.
Moorman, Kizer & Reitzel, Inc.
Engineering Firm or other consultant
Dennis A- Gilbert
Individual contact person (type or print)
dgilbertgmkrinc.com
E-mail Address
910-484-5191
Telephone
910-484-0388
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 informatbin provided herein
1
Nathaniel Johnson Managing Member
Type of print name Title or Authority
� -�� l01 ►0.�a-i
Signature Date
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i, t_ O I I'l nS tl f- , a Notary Public of the` _County of ATV i�
State of North Carolina, hereby certify that j4CCRf kQj AOVJ02�)n 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 J4-day of , r , 20------- - ------ I O_nam"OL
Notary
an Qtllns Hair
N4 Public
Hoke County My commission expires o
North caroling
L
ission Expires 10 31 2023