NCC223407_FRO Submitted_20220930

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 Adams Point Amenity Site
2. Location of land -disturbing activity: City or Township Cleveland Township
Highway/StreetFleldtrial Circle Latitude35,5810 Longitude-78.5876
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1 .25
6. Amount of fee enclosed: $760 (paid) 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 Z No ❑ Enclosed_
E?
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name- George A Nazal (Tony) E-mail Address [e-mail]
TelephoneCAManagement 919-741-5285 Cell # tnazal 919-418-6534 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Adams Point Community Association Inc.
Name Telephone
c/o Community Association Management PO Box 79032
Current Mailing Address Current Street Address
Charlotte NC 28271-0030
City State
10. Deed Book No. 04022
Part B.
Zip City
Page No. 0860
State
Fax Number
Zip
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):
Adams Point Community Association, Inc. [e-mail]
Name E-mail Address
c/o Community Association Management PO Box 79032 same
Current Mailing Address
Charlotte NC 28271-0030
City State Zip
Telephone CAManagement 919-741-5285
Current Street Address
City State Zip
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
Telephone 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:
Community Association Management [e-mail]
Name of Registered Agent E-mail Address
PO Box 79032 Same
Current Mailing Address Current Street Address
Charlotte NC 28271
City
State Zip City
Telephone [phone]
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.
George Nazal Tony)
Type or pri9k name /
Signature
President
Title or Authority
I- -2 Z_
Date
1,[4l I�� i� �rr�1C: YlS , a Notary Public of the County of _ �r ,lrtrl5�n
State of North Carolina, hereby certify that 0-.7-60_Cc1� /A LAC,Zr 1 appeared
personally before me this day and being duly swor acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this =day of 20�;LQL
�L1 uc� _h
Holland I Adams Notary
10
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