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HomeMy WebLinkAboutNCC215922_FRO Submitted_20211026JOHNSTON 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 iniormation unavailable, place N/A in the blank.) Part A. Project Name: Little River Plantation — Phase Three, Section Two 2. Location of land -disturbing activity: County: Johnston City or Township: O'Neals Highway/Street: NC 96 Latitude: 35.69780 Longitude:-78.27003 3. Approximate date land -disturbing activity will commence: January 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0 acres 6. Amount of fee enclosed: Prev Paid . The application fee of $300.00 per acre (rounded up to the next acre) is assessed for the first 10 acres and an additional $100 per acre for each additional acre (rounded up to the next acre). 7. Has an erosion and sediment control plan been filed? Yes X No Enclosed: 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name: P. Scott Lee E-mail Address: scott(&scottleehomes.com Telephone: (919) 553-2085 Cell: (919) 369-1937 Fax: (919) 9. Landowner(s) of Record (attach accompanied page to list additional owners): LAST Investments, LLC (919) 553-3242 (919) Name Telephone Fax 104 State Avenue, Suite 103 104 State Avenue, Suite 103 Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip 10. Deed Book No.: 5606 Page No.: 908 — 910 Provide a copy of the most current deed. Part B. 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): LAST Investments. LLC Name 104 State Avenue, Suite 103 Current Mailing Address Clayton NC 27520 City State Zip Telephone: (919) 553-2085 scottna scottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 City State Zip Fax (919) 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 Current Mailing Address City State Telephone E-mail Address Current Street Address Zip City Fax Number State Zip (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: P. Scott Lee Name of Registered Agent 104 State Avenue, Suite 103 Current Mailing Address Clayton NC 27520 City State Zip Telephone (919) 553-2085 scottCcDscottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 City State Zip Fax Number (919) 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. P Scott Lee T e or prin e Si ' ature Registered Agent, LAST Investments, LLC Title or Authority Y-- I, _ Z,4)2-t Date I, S-,>.sgn G. , a Notary Public of the County of State of North Carolina, hereby certify that personally before me this day and being executed by him. Witness my hand and notarial seal, this X k appeared duly sworn acknowledged that the above form was day of , 2021 Notary My commission expires 0. O