NCC233485_FRO Submitted_20231122

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FINANCIAL RESPONBIBIUlY L���' KET AK-3 FORI d
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SEDIMENTATION POLLUTION COMROL 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 NIA in the blank.)
Fart A.
`
1. Project l�lene ft,,9 isdo m for the`- Heart
2. Location of land-disturbing activity: Cnran __-.----JOHNSTON City or Township_ _ CLAYT©RI
ate Highway/Street vy` C __.- Latitudes 35'.6S 20��} Longitude
3. Approximate date land-disturbing activity will commando: May 1 St, 2023
Commercial
4. Purpose of development(residential,commercial,industrial,institutional,etc.):____ __�
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1`24 Acres
6. Has en erosion and sediment control plan been filed? Yes V No Enclosed �.._,,...,
7. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
me Dan Pabst e-mail Address dpabstepabstdesign.cotn _.._
Telephone 919 8, 4399 Cell tt Fax#
a. Landoviner(s)of Record(attach accompanied page to list additional owners):
Wisdom International 866 482 4253
Name Telephone Fax Number2703 Jones Franklin Road, Suite 105 2703 Jones Franklin Road, Suite 105
Current Mailing Address Current Street Address
NO 27518 Gary NC 27518
city State Zip City estate Zip
9. Deed Book No. `86 �._ Page No,77-75._ Provide a cipy of the most current dead.
Pan 5,
l. 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.
SDK bi 5 t U/ ,rp . ..cif .�'�a R de✓r?_
Name -- .�...__ E-mail Address
OtUr v n/ Pt/WE
Current Mailing Address Current Street Address
City State Zip City:�: •State-
qr -/
Zip
T�Fephonq_._
/(,/�] - C /"4``^' roc Number-.

2. (a)If the Financially Responsible Party is note 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 Certificete eV 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.
__#_. hA_T
Type or;pri t Male 0. Title or Autharity
...C.. , i
Signature / Date
..._
i, 4,CIU.(erN. 01)X.70-1 1 , a Notary Public of the County of
State of North Carolina, hereby certify that e\.cy ..,..Jr- ..,16(1. _. appeared
pereonally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal,this 1(-911\ day f_ NOvkm_ y_ ,20.=.? _
4t, lit
, Notary
LAUREN M KAY
Notary Public My commisskm expires ti-_,A41,j i 4,,, ,.__i3O3:9—
Alake Co.,North Carolina
'Av Commission Expires April 20,2027
„...._.