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HomeMy WebLinkAboutNCC223823_FRO Submitted_20221115FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and Sedimentation Control Ordinance and are required to complete this form. (Please type or print and, if the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.) Part A. 1. Project Name Johnston Health Medical Office Building 2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON Highway/Street NC Hwy. 42W Latitude 35.63279 Longitude -78.49802 3. Approximate date land -disturbing activity will commence: September 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Medical Office 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.7 acres 6. Has an erosion and sediment control plan been filed? Yes ✓ No Enclosed 7. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Kyle McDermott E-mail Address Kyle.McDermott@unchealth.unc.edu Telephone 919-585-8000 cell # 919-398-8082 Fax # q lq - b 5— 066 ✓ 8. Landowner(s) of Record (attach accompanied page to list additional owners): Johnston Memorial Hospital Authority 919-585-8000 Gi Name Telephone Fax Number P.O. Box 1376 2138 NC Highway 42 W. Current Mailing Address Current Street Address Smithfield NC 27577 Clayton NC 27520 City State Zip City State Zip 9. Deed Book No. 03557 Page No. 0788 Provide a copy of the most current deed. Part B. 1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship the name of the owner or manager may be listed as the financially responsible party. Johnston Memorial Hospital Authority Name 2138 NC Highway 42 W. Current Mailing Address Clayton NC 27520 City State Zip Telephone 919-585-8000 Kyle.McDermott@unchealth.unc.edu E-mail Address 2138 NC Highway 42 W. Current Street Address Clayton NC 27520 City j State Zip Zip c Fax Number 9 1 �. ^5 9 - Sou 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: N/A Name Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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: NA Name of Registered Agent Current Mailing Address aty Telephone E-mail Address Current Street Address State Zip City State Zip 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. Uo�e %-es. S� 6 r _.�rv% ceJ Title or Authority ,?--la - 26,ZZ Date 1, S. M Q I �1 a Notary Public of the County of State of North Carolina, hereby certify that appeared personally before me this day and being duly swo n acknowledged that the above form was executed by him. Witness my hand and notarial seal, Notary Public s r?�� County MY Com`t�r W n Ex 1 S= Tiq C P, Ok this day of Vl _, 202-ZI Notary My commission expires �v�