NCC223133_FRO Submitted_20220908

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 Laurer Tract
2. Location of land -disturbing activity: City or Township Welders
Highway/Street Maggie Way Latitude 35.73688 Longitude-78.38149
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Resident
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 42.02
6. Amount of fee enclosed: $ 8050 . 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. 380x10=380i
33x125=412:
7. Has an erosion and sediment control plan been filed? Yes 1:1No Enclosed 77
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Lipscomb E-mail [e-mail]
Telephone [phone] Cell # Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Maggie Way, LLC
919-422-4704 NIA
Name
Telephone Fax Number
328 E Main Street
Current Mailing Address
Current Street Address
Clayton NC
27520
City State
Zip City State Zip
10. Deed Book No. 5324, 5996
Page No 61 1, 984
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):
Maggie Way, LLC
[e-mail]
Name
E-mail Address
328 E Main Street
Current Mailing Address
Current Street Address
Clayton NC
27520
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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address
NIA NIA
City State
Current Street Address
N/A NIA
Zip City
TelephoneN/A Fax Number N/A
NIA NIA
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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA NIA NIA
City
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City
Fax Number N/A
NIA NIA
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.
James Lipscomb
Type or prinme
Signature
Managing Member
Title or Authority
1�2 !:;;2
Date
Q �'1 l �t` c,�LG�, , f 4ti 4�Y? a Notary Public of the County of
State of North Carolina, hereby certify that I (,tWS LI , appeared
personally before me this day and being duly sworn ackn wledged that the above form was
executed by him.
Witness my handandnotarial seal, this
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