NCC221978_FRO Submitted_20220526

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 NIA in the blank.)
Part A.
1. Project Name Views at Flowers Apartments
2. Location of [and -disturbing activity: City or Township Welders
Highway/Street NC 42 Latitude 35.655213 Longitude-78.339342
3. Approximate date land -disturbing activity will commence: May 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.80
6. Amount of fee enclosed: $4,300 . 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 Alex Buffington E-mail Address [e-mail]
Telephone Cell # 336-404-8375 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Views at Flowers, LLC 336-383-5906
10
Name Telephone Fax Number
PO Box 9519 1400 West Northwood Street
Current Mailing Address Current Street Address
Greensboro NC 27429 Greensboro NC 27408
City State Zip City State Zip
Deed Book No. 6149 Page No. 75-79
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):
The Views at Flowers, LLC [e-mail]
Name E-mail Address
PO Box 9519 1400 West Northwood Street
Current Mailing Address Current Street Address
Greensboro NC 27429 Greensboro NC 27408
City State Zip
City State Zip
Telephone [phone] Fax Number,

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 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 information should there be any change in the information provided herein.
Brantley White Ma 6(&-
Type or print name Title or Aut ority
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Si ure Date
I, L• ACV hits , a Notary Public of the County of rd
State of North Carolina, hereby certify that Urar+C � (N o kz 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 2.,.Z-day of, 20ZZ
ALt
otary
Krist ,i,,Aarhus
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Randolph County My commission expires
North Carolina
My Commission Expires 9/28/2025