NCC221742_FRO Submitted_20220512

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Cottages at Wilson's Mills SID ( Lots # 2,4,5,8,10,14,21222,23,37,40,41)
2. Location of land -disturbing activity: City or Township wilsan's Mills Township
Highway/Street
Hanover Court and ImperialOnve Latitude 35.60655 Longitude -78.35633
3. 'Approximate date land -disturbing activity will commence: AS soon as possible
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.26 AC
8. Amount of fee enclosed: $ 1,200.00 . 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). Individual residential lots plans are $100 per lot.
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 Pamela Geddie E-mail Address [e-mail]
Telephone [phone] cell # 910-709-9801 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached list
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. See attached list Page No.
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):
Caviness & Cates Building and Development company [e-mail]
Name E-mail Address
639 Executive Place , Suite 400 Same
Current Mailing Address Current Street Address
Fayetteville N.C. 28305 Same
City State Zip City State Zip
Telephone [phone] Fax Number 910-481-0585

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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City
State zip City
Telephone 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.
Christoph r E. Cates Vice President
Type or pr' ame Title or Authority
Ciro i it Date
a Notary
State of North Carolina, hereby certify that
personally before me this day and being my sworn
executed by him.
Witness my hand and notarial seal, this _C-
S e a I Gne`mSssd
My Q
My of /
of the County of
"(_:CZ=Eappeared
ed that the above form was
Notary
My commission expires
r

Cottages at Wiison Miil's Subdivision
Lot ##'s (2,4,5,8,10,14,21,22,23,37,40 & 41)
Lot #
Owner
D.B./P.G.
Pin
Permission Letter Provided
lot Address
2
Hoosier Daddy, LLC
05319/02255
169701-16-2108
YES
Hanover Court
4
Hoosier Daddy, LLC
05319/02255
16701-06-9138
YES
Hanover Court
5
Hoosier Daddy, LLC
05319/02255
169701-06-8188
YES
Hanover Court
8
Caviness & Cates
6202/183
169701-06-7117
NA
Hanover Court
10
Caviness & Cates
6202/183
169701-06-6083
NA
Hanover Court
14
Caviness & Cates
6202/183
169701-15-0336
NA
Hanover Court
21
Caviness & Cates
6202/325
169701-15-4369
NA
Imperial Drive
22
Caviness & Cates
6202/325
169701-15-5329
NA
Imperial Drive
23
Caviness & Cates
6202/325
169701-15-5389
NA
Imperial Drive
37
Hoosier Daddy, LLC
05319/02255
16701-16-3189
YES
Hanover Court
40
Hoosier Daddy, LLC
05319/02255
169701-16-3030
YES
Hanover Court
41
Hoosier Daddy, LLC
05319/02255
169701-16-2080
YES
Hanover Court