NCC241528_FRO Submitted_20240610

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. I�
1. Project Name Ll/a/ 7efer Su8b1V/5/0A/
2. Location of land-disturbing activity: City or Township BAUA/ER �w�t/6s//P
Highway/Street CRo5sRa4h5 deoA4 Latitude 35. "36060 Longitude 76.477/0
3. Approximate date land-disturbing activity will commence: C%od/ REC.mPr aF PE.R4ir.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RFSJ ,t/ri4L
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): /0.20
6. Amount of fee enclosed: $ 4, 125.00 . The application fee of$400.00 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 No Enclosed ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name LAMA/ CL/Fred E-mail Address /ahnye/iI&.onAui/der"a9ma,/.COM
Telephone (919) 97/— 5353 Cell#(9)9) 97/— 5353 Fax# (919) 94-3100
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ALLau s teossao4es —
Lw 20EVELopME4tIT L.L.C. (9)9 ) 97/— 5353 (919) 934-- 3106
Name Telephone Fax Number
5160 A/C / a dum v 42 d✓Esr 5160 A/C Akvim v 42 W sr
Current Mailing Address Current Street Address
GARuEg AOC 27529 G4R A/C 27529
City State Zip City State Zip
10. Deed Book No. 06459 Page No. 090/
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):
Ac�u's Caass corns —
LAW Dev&.op9aj r L.L.C. fans c1i-FfaObr ilder'9nail. Corn
Name E-m I Address
5160 A& //6a/wAy 42 lilesr 5 4e, A/C MGM WAY 42 dt/Esr
Current Mailing Address Current Street Address
&ARA/Le ABG 27529 6.41eivEz A/C 27529
City State Zip City State Zip
Telephone (919) 97/—5153 Fax Number (9/9) 934 - 3/00

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 p
e E-mail Address
IJ/A kl/A
Current Mailing Address Current Street Address
i /A IJ/A
Ci y State Zip Ci y State Zip
Telephone Ski/A Fax Number N/A
(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:
Al/A 63/A
Name of Registered Agent E- ail Address
kVA AI/A
Current Mailing Address Current Street Address
u/A N /A
Oily B State Zip Ci y State Zip
Telephone Kr /A Fax Number AI/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 information should there be any change in the information provided herein.
LituA Y CLiFina it9E.18E s11,,aafx.
Type or primname Title or Authority
CGy�, — te G 'JJ
Signature Date
I, S'ar G . u S , a Notary Public of the County of ___\==.\-NiN -on
State of North Carolina, hereby certify that L..ckrr‘,._ C_..-V% A-tnl appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this \C. .. day of �a �T-vc4 f , 20
J• ''pTA% , T>;'-" �� ,
``c':•°�a ,„,,r"' Notary
Seal
O Idi My commission expires ./0-o/.�csZCs:2_
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