NCC220033_FRO Submitted_20220107

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 NIA in the blank.)
Part A.
1
Project Name Andrews Landing Subdivision
2. Location of land -disturbing activity: City or TownshipO'Neals Township
Highway/Street SR 1722 - Mudharn Road Latitude35,775 Longitude-7S.305
3. Approximate date land -disturbing activity will commence: Upon receipt of permit.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):18.0
6. Amount of fee enclosed: $4,800.00 The application fee of $380.00 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 erasion and sediment control issues arise during land -disturbing activity:
Name Andrew Perry E-mail Address [e-mail]
Telephone (919) 592 - 2790 Cell # (919) 592 - 2790 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Phoenix Building Concepts, L.L.C. (919) 592 - 2790 NIA
Name Telephone Fax Number
10764 Patrician Way 10764 Patrician Way
Current Mailing Address Current Street Address
Zebulon NC 27597 Zebulon NC 27597
City State
10. Deed Book No, 05797
Part B.
Zip City
Page No.0984
State
Zip
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):
Phoenix Building Concepts, L.L.C. [e-mail]
Name E-mail Address
10764 Patrician Way 10764 Patrician Way
Current Mailing Address Current Street Address
Zebulon NC 27597 Zebulon NC 27597
City State Zip City State Zip
Telephone (919) 592 - 2790 Fax Number N/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-,
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ry JA
E ail Address
u/A MIA
Current Mailing Address Cu rent Street Address
MIA MIA
Cit State Zip CFi State T Zip
Telephone u I 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:
of A
J me of Registered Agent
M 1A
Address
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CLfrrent
Mailing Address
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resent Street Address _._ ........,......._.
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City
State
Zip C4
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State Zip
Telephone IJ 1A Fax Number 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 " ormation provided herein.
l` - . ,� '
Type or print nam Title r Authority
h014
tgnature Date
I, #5 a Notary Public of the County of 7 �1C,lri
State of North Carolina, hereby certify that UyNAr r- � trOJ appeared
personally before me this day and being duly sworn acknowledged Ithat the above form was
executed by him.
Witness my hand and notarial seal, this _day of t,i ILA 20-L-) _-
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0 TA'41- NotaryL p ,
� tr Seal
_ = s My commission expires
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