NCC216030_FRO Submitted_20211029

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: Lowery Meadows — EC Plan for Lots 1 — 4, 23, 33, 35, and 36
2. Location of land -disturbing activity: County: Johnston City or Township: Elevation
Highway/Street: Lowery Lane Latitude: 35.4968 Longitude: - 78.5423
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow & waste areas): 3.2 ac (prey prmtd)
6. Amount of fee enclosed: $ 0 (prev paid) . The application fee of $330.00 per acre (rounded up to
the next acre) is assessed for the first 10 acres and an additional $110 per acre for each additional
acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Scott Lee E-mail Address: laura(a)scottleehomes.com
Telephone: [phone] Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Scott Lee Homes, Inc. [phone] (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
5665
522 - 526
10. Deed Book No.: 6002
Page No.:
758 — 760
Provide a copy of the most current deed.
5950
504 — 506
5950
507 - 509
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):
Scott Lee Homes. Inc.
Name
104 State Avenue, Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone: [phone]
laura (r-scottleehom es. co m
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
E-mail Address
Current Street Address
State Zip City
Telephone 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. -
Laura S. Lee
Name of Registered Agent
104 State Avenue Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone [phone]
laura(@.scottleehomes.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). 1 agree to provide
corrected information should there be any change in the information provided herein.
P S.c,ott Lee
Type or nt -rrame
Signature
President, Scott Lee Homes, Inc.
Title or Authority
Date
a Notary Public of the County of iY
State of North Carolina, hereby certify that 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 day of 2021
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Notary
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