NCC222180_FRO Submitted_20220622

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 Burch Brothers Flooring Site Plan
2. Location of land -disturbing activity: City or Township Cleveland Township
Highway/Street Son -Lan Parkway Latitude 35.61210 Longitude-78.56290
3. Approximate date land -disturbing activity will commence: Upon receipt of permit.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.87
6. Amount of fee enclosed: $ 760.00 . 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 Jonathan Burch
E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J Burch Investments,
L.L.C_ [phone] NIA
Name
Telephone Fax Number
P.O. Box 118
182 Cleveland Crossing Drive, Suite 400
Current Mailing Address
Current Street Address
Morrisville NC
27560 Garner NC 27529
City State
Zip City State Zip
10. Deed Book No. 6214
Page No. 963-965
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):
J Burch Investments,
L.L.C. [e-mail]
Name
E-mail Address
P_O. Box 118
182 Cleveland Crossing Drive, Suite 400
Current Mailing Address
Current Street Address
Morrisville NC
275fi0 Garner NC 27529
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:
M
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone NIA
Fax Number NIA
(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 tame. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone NIA
Fax Number NIA
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 inflation should there be any change in the information provided herein.
�"pe or pri t name
�'�ignature
e or Authority
Date
lc,)05Ot a Notary Public of the County of ✓�
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State of North Carolina, hereby certify that o ���r c w1Voi_;�Wfc�, �". 'C�4peared
personally before me this day and being duly sworn ackn6wledged that the above form was
executed by him.
Witness my hand and notarial seal, this I'x—� day of fleag- C.V-, , 209A
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rasioii i Notary
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My commission expires_1J�
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