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Home My WebLink AboutNCC242667_FRO Submitted_20240830 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 CE-JAIZ EibC- SUBBiViSiot/ 2. Location of land-disturbing activity: City or Township PLEASAIJT 62 oVE- TwLJSA/iP OLb FA,IGRou.Vb Highway/Street Ro.4b Latitude 35.50100 Longitude - 76.6O8O0 3. Approximate date land-disturbing activity will commence: 6// /z4 4. Purpose of development(residential, commercial, industrial, institutional, etc.): IQESICE4/71AL- 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): /4- 24 de- AM : A: 6. Amount of fee enclosed: $ FRs✓,ou5LY PA/to . 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 LAmJfY CL/FTo,I E-mail Address JRnny /r'conAue/der-05ma/coen Telephone (919) 97/- 5153 Cell# (919) 97/-5553 Fax# (919) 954- 3/OO 9. Landowner(s)of Record (attach accompanied page to list additional owners): OLb FAIRC,RouAlb Rah - btu/ L.L.C. (919� 97/- 5353 (919) 934- 3100 _ Nametelephone `Fax Number 63 ✓ e A/ CouRrr 63 ✓ ou L'ov,r Current Mailing Address Current Street Address W Lwow 6PR,j/GS A/C. 27592 Wtdow gPitm044 ,tk. 27592. City State Zip City State Zip 10. Deed Book No. 066773 Page No. 0995 O6474 0989 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): g n kliQ64'euAl* Z4b LA./! L.L.G. /anPfebu1onzwiddr/s3 Omni1 tom Name E-mail Address J 65 1✓F oil Couzr 65 ✓ ea/ Cduzr Current Mailing Address Current Street Address WILLOW Jr'PR,A/GS Alt 2 7592_ L'OILLOW SPZ,d65 /J0 Z7592_ City State Zip City State Zip Telephone (919) 97/- 5353 Fax Number 014) 934-3/60 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: It /A u/A N me E-mail Address NIA u/A C rrent Mailing Address Current Street Address City State Zip City State Zip Telephone IJ/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: u/A NIA N me of Registered Agent E- ail Address A Al/A Current Mailing Address Current Street Address u/A 1J/A CI State Zip City State Zip Telephone Al/A Fax Number Ad/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. LAxruv CL.,rov N#EJABEZ. AbIAG.. Type or name Title or Authority / ure Date I, c r'r-\O, I Z-c 10r a Notary Public of the County of J�t State of North Carolina, hereby certify that LO\YlY\ G \ckir,n appeared personally before me this day and being duly swoin acknowledged that the above form was executed by him. I 4 Witness my hand and notarial seal, this 1 1 `4 day of f 20 Notary My commission expires I ) LAU VICTORIA AMBRIZ-FLORES Notary Public-North Carolina Wayne County My Commission Expires Jan 30, 2028 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 C.EJNA2 Z,t E. SueDIVl6/0I1 2. Location of land-disturbing activity: City or Township PLa4.sAOT Ors Fa,RGRzuAJ Highway/Street Ross Latitude 15. 50120 Longitude - 78.6,0750 3. Approximate date land-disturbing activity will commence: t Polo VFr€IPT OF PE.Zk IT. 4. Purpose of development(residential, commercial, industrial, institutional, etc.): 7.6-61DE..krriAL- 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2/0.74 6. Amount of fee enclosed: $ 8, 325.00 . The application fee of$450.00 per acre (rounded up to the next acre) is assessed for the first 10 acres and an additional $225 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 L.AUUY CL/FToa/ E-mail Address Ian nycli-Fi,onbui/der¶gmail.Gorr, Telephone (919) 97/— 5353 Cell# (9)9) 97/- 5353 Fax# (919) 934- 3100 9. Landowner(s) of Record (attach accompanied page to list additional owners): OLD Fat6Ab.Jlb Roe1 - Lev L.L.C. (9)9 ) 97/ - 5353 (919) 934- 31oo Name Telephone Fax Number 5160 A/C di&i/ My 42 WEsr 5160 ode AU/WAY 42 1t/Esr Current Mailing Address Current Street Address GARVER. AL 27529 &AieuEdz 27529 City State Zip City State Zip 06675 0995 10. Deed Book No. 06676 Page No. o9e9 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): OLA £A/RGRoiIi1D ZAv - LAA1 L.L.C. lannycllInbu,/der .)jnw,l.coin Name / E-mail Address 5160 A C. !IIGIIH/4Y 42 WW.sr 5160 1JG /h&WW4Y 42 ukEsr Current Mailing Address Current Street Address GAZuE.X 27529 GArzLIEJE )JC. 27529 City State Zip City State Zip Telephone (919) 971 - 5355 Fax Number (919) 934 - 3100 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: u/A N/A Name E-mail Address N/A IuiA Current Mailing Address C Ali Street Address NiA iu/A C' y State Zip Ci y State Zip Telephone N/A Fax Number 1/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 u/A Name of Registered Agent E-mail Address Vli /A N/A Current Mailing Address Current Street Address u/A N/A Ci y State Zip Cify State Zip Telephone N/A 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 information should there be any change in the information provided herein. LA1.1t ' GLJPt,1J MgASEIL MANAGER_ Ty e or int name Title or Authority .4_, 5 -- a_ 2 - ,a., ,../. (Si ature Date ------------ I, A7 ua� 15 i n Ml)rr , a Notary Public of the County of ),, 1V\Sc,I(-\ State of North Carolina, hereby certify that L4.:;).7-1Y1L f'-K . ` + '1� appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. `i --`` Witness my hand and notarial seal, this -� \ day of 01, � � , 20 - E rK/N - ,,, qAJ1/6 dJ-121011/47) r•Potx r vm z , .s.: .::: �" p�= Notary \- teal '"'i. IF _ s.o`: My commission expires L—� _. 1 '- ( )(� ,,,„ONCOtJt{ ;0,"