NCC220194_FRO Submitted_20220111

JOHSTON 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: Spring Branch — EC Plan for Lots 1 5 7 8 11 13 15, 16, 18, 22 - 24, & 26
2. Location of land -disturbing activity: County: Johnston City or Township: Elevation
Highway/Street: Shdv Oks Dr, Tkwd Cir, Mdx Cv Latitude: 35.4904 Longitude: - 78.5569
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.4 acres
6. Amount of fee enclosed: $ 1,300.00 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). ($100 per lot for residential lot EC plan)
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: Matthew Norris E-mail Address: mattnorris1985(cDyahoo.com
Telephone: [phone] Cell: [phone] Fax: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cumberland Homes, Inc. [phone] [phone]
Name Telephone Fax
Post Office Box 727 108 Commerce Drive
Current Mailing Address Current Street Address
Dunn NC 28335 Dunn NC 28334
City State Zip City State Zip
10. Deed Book No.: Attached Page No.: Attached Provide a copy of the most current deed.
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):
Cumberland Homes. Inc. _
Name
Post Office Box 727
Current Mailing Address
Dunn NC 28335
City State Zip
Telephone: [phone]
mattnorris 1985(a)yahoo. com
E-mail Address
108 Commerce Drive
Current Street Address
Dunn NC 28334
City State Zip
Fax [phone]

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:
Matthew H. Norris
Name of Registered Agent
Post Office Box 727
Current Mailing Address
Dunn NC 28335
City State Zip
Telephone [phone]
mattnorris 1985a-va hoo.com
E-mail Address
108 Commerce Drive
Current Street Address
Dunn NC 28334
City State Zip
Fax Number [phone]
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.
Matthew H. Norris President, Cumberland Homes, Inc.
Type o print na Title or Authority
Si ature LDate
a Notary Public of the County of
State of No h ga�he6k&prtify that A.,�� �r� N . �c��. S appeared
personals bore me this d'Syd being duly sworn acknowledged that the above form was
executc,iby him. ';�\OTA9 h
Witness hand and notarial seal this )M day of JV Ovt^j e1- 2021
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