NCC232591_FRO Submitted_20230927

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 N/A in the blank.)
Part A.
1. Project Name_
EMI 4'1AbiniA .Re. orn E. 1.10 FVFA
2. Location of land-disturbing activity: City or Township 0.44TOP
Highway/Street Poi,.) D sC TWvJ Latitude 35.6914 5a Longitude — '7 . 39 sec
3. Approximate date land-disturbing activity will commence: S• 21. 2OZ 3
4. Purpose of development(residential, commercial, industrial, institutional, etc.): i 1J al►ST21 A L
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 30. I S
6. Amount of fee enclosed: $ (0625 clt
. 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 planspl are$100 per lot.
7. Has an erosion and sediment control plan been filed? Yes'V No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activit :
co IzKI361.(Am
Name Ckg...15 L.A •otT E-mail Address C4sRiS. C.Ak6PJTCe_ 3�.t•.
Telephone GLq•613S &11') Cell# SAME Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
kioile) W6QDI.SK q Iq-s St) ►2260
Name Telephone Fax Number
3G)12 14w4i4rz vJ Rd
Current Mailing Address Current Street Address
C(ilrroPJ N.C. 2'7 S2'7
City State Zip City State Zip
10. Deed Book No. Page No.
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):
BE&K Building Group GI.t2iS. CA3014'v aE _ L,�
Name E-mail Address l'
Pilo R red
Current Mailing Address Current Street Address
Mo22\SVI LLE NC, 2751c0
City State Zip City State Zip

Telephone -q 35- 0q t 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 State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
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Ty•- ar pri n-.y - 'l�/ Title or Authority
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7atu�re Date
I, 00)1n06. LYG, , a Notary Public of the County of 11
State of North Carolina, hereby certify that " Y Z £S1'1OLW) appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness qad 49 rial seal, this Z day of � , 20 2-
\J,0 c561,-IdL
\.\c' 2 Notary
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C® My commission expires 10.28 Z3
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