NCC221259_FRO Submitted_20220404

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 N/A in the blank.)
Part A.
Brant Station - Phase 1
1, Project Name
2. Location of land -disturbing activity: City or Township Johnston County
Highway/Street Cornwallis Road, SR-1525 Latitude 35.452390 Longitude 35.452390
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16 acres
6. Amount of fee enclosed: $ Previously paid , The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre (rounded up to the next acre).
7.
Has an erosion and sediment control plan been filed? Yes x No Enclosed
8.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Colleen Duryea
E-mail Address [e-mail]
Telephone [phone]
Cell # 919452-7260 Fax #
9.
Landowner(s) of Record (attach accompanied page to list additional owners):
William Charles Cozart
Name
Telephone Fax Number
3724 National Drive Ste 130
3724 National Drive Ste 130
Current Mailing Address
Current Street Address
Raleigh NC
27612 Raleigh NC 27612
City State
Zip City State Zip
10.
Deed Book No. 04709
Page No. 0957
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):
Rex Vick, RBV 40 LLC
[e-mail]
Name
E-mail Address
3434 Kildaire Farm Road Suite 135
2046 Energy Drive
Current Mailing Address
Current Street Address
Cary NC
27518 Apex NC 27502
City State
Zip City State Zip
Telephone [phone]
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:
N/A
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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:
N/A
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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 i formatioon should there be any change in the information provided herein.
Type or print name ��Title or Authority
Signature
Date
I, ,1 a Notary Public of the County of
ACE -
State of North Carolina, hereby certify that Y j cl°` 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 31 day of20
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CHRMTINE OSBORNE
NOTARY PUBLIC
WAKE COUNTY, N.C.
S Commission Expires 02-10-24
Notary
My commission expires 0 2 / z;— Z Y