NCC241830_FRO Submitted_20240625

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 LEGACY FARMS Su$NviSfoal
r,1
0
2. Location of land-disturbing activity: City or Township AIE.ALoS Tow,isa►p
AAIT,cCN
Highway/Street CHrigoi RoAb Latitude 45.69900 Longitude -70.23430
3. Approximate date land-disturbing activity will commence: LAUe b!S11h 4dtE i,/AS to4.4EJJGE.e.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): KESmE4/71AL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.IS s1G.
A/orEs: Ftz.
6. Amount of fee enclosed: $ PREVAouS4Y P.dlt1 . 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 T1.4011 Eb QARDS E-mail Address teciwarYknc'. mai/,con?
Telephone (919) 247- 5920 Cell#(919) 247- 592D Fax# NVA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
TLC Io.44 L.L.G. (919) 247- 59W WIA
Name l Telep fione F x Number
5Z9i VC 1 G//w.4Y Z3/ 5291 VC ll/s,1w4Y Z 31
Current Mailing Address Current Street Address
ZEsvt.ou A1G 27597 .Z ut,o,J NG 27597
City State Zip City State Zip
10. Deed Book No. 06650 Page No. 0867
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):
YLE livabS s L.L.C. +._edwardsncrJ.3rnaiJ.corn
Name E-mail Address
529I A/L Id/s1w4v Z3/ 529I AIC liagw.SY Z3/
Current Mailing Address Current Street Address
ZEBut.o.t1 AIG 27597 ZEavi / Ak 27597
City State Zip City State Zip
Telephone (919) 247 — Fi920 Fax Number iJ //A

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:
NA NA
N me E i mail Address
N/A N/A
Current Mailing Address Current Street Address
NIA AIIA
Ci y State Zip Ci y State Zip
Telephone 4/A Fax Number u/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:
N/A AI IA
N me of Registered Agent E-hail Address
N/A NI A
Current Mailing Address Cent Street Address
Citj, State Zip Ci State Zip
Telephone N/A Fax Number !i♦/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.
%pti , eZWAR-4tS at/AdIrt.--
Type or print name Title or Authority
1 :9W44r/e.44(__-
natur Date
I, tt.1 (A-) `1 1(�S I I IC>rr I S, a Notary Public of the County of J
-rC. 1 k-\ 1
certify �C)m ICY 1—Gt -�
"State of North Carolina, herebythat 1��,�3 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand„ara l„ ptarial seal, this day of J(.4 r1t' , 20 c.--1
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� .J�n.� fry i\(ycr
.12 0"__ Notary
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ty ,'Z�.' My commission expires �� �� �
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