NCC230277_FRO Submitted_20230131

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.
2.
3.
4.
5.
6.
7.
8.
Project Name HANNAH CREEK ROAD TRACT
Location of land -disturbing activity: City or Township BENSON NC
Highway/Street SR 1171 Latitude 35.38259 Longitude-78.49756
Approximate date land -disturbing activity will commence: 4/11 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.84 ACRES
Amount of fee enclosed: $ 1,900.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name SAL SERAFANO E-mail Address [e-mail]
Telephone [phone] cell # 919-909-3495 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GRINDSTONE ACQUISITIONS, LLC 919-262-6828 N/A
Name Telephone Fax Number
716 WILLOW WINDS DR. 201 BELLARIS ST.
Current Mailing Address
RALEIGH NC 27603
City
State Zip
10. Deed Book No. 551 2 Page No. 51
Part B.
Current Street Address
GARNER NC 27529
City State 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):
QUALITY ONE CONTRACTING, LLC [e-mail]
Name
P.O. BOX 1444
Current Mailing Address
CARY NC
City State
Telephone [phone]
27512
E-mail Address
503 E. FRANKLIN ST.
Current Street Address
RALEIGH NC
Zip City
Fax Number N/A
State
27604
Zip

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
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;
Salvatore Serafano
Name of Registered Agent
P.O. BOX 1444
Current Mailing Address
[e-mail]
E-mail Address
2540 ELM GRANT
Current Street Address
CARY INC 27512 NEW HILL NC 27562
City State Zip City State Zip
Telephone [phone]
Fax Number N/A
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 n orm tion should there be any change in the information provided herein.
Type or print e Title or Authority
_ Z�1102-2
Signature LDate
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I, a Notary Public of the County of _�/c
State of North Carolina, hereby certify that % V-C c.�a 7iW7 0 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and
Seal
LP day of F?15V Or-t , 20
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R11. A
i MY COMM. Exp.
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2;-7
Notary
My commission expires 5�2_7/2y02,}