NCC221250_FRO Submitted_20220404

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FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
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 NIA in the blank.)
Part A.
1. Project Name Clayton Industrial
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street Shotwell Road Latitude 35°39'41 "N Longitude 78°28'45"W
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22.2
6. Has an erosion and sediment control plan been filed? Yes No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dave Williams E-mail [e-mail]
Telephone [phone] Cell # Fax #
A
Landowner(s) of Record (attach accompanied page to list additional owners):
NBPIII Clayton LLC
Name
Telephone Fax Number
401 Edgewater Place
Current Mailing Address
Current Street Address
Wakefield MA
01880
City State
Zip City State Zip
9. deed Book No. 6139
Page No. 226-230 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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.
NBPIII Clayton LLC
dean.atkins(_Unothbridgecre.com
Name
E-mail Address
401 Edgewater Place
Current Mailing Address
Current Street Address
Wakefield MA
01880
City State
Zip City State Zip
Telephone [phone]
Fax Number

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
Intercon Building Company LLC [e-mail]
Name
211 Atherton Street
Current Mailing Address
Charlotte NC 28234
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
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 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 State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Dave Williams Authorized Agent
or ame
Signature
Title or Authority
Q - z z
Date
I, a Notary Public of the County of
State o aroiina, hereby certify that Mod 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 day of , 2�__
STEPHANIE PSAROVDIS
Notary Public - State of South Carolina
MY Com"8@0 Expires June 30. 2030
My commission expi