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HomeMy WebLinkAboutNCC220919_FRO Submitted_20220301FINANCIAL RESPONSIBILITYIOWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and Sedimentation Control Ordinance and are required to complete this form. (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 Ashcroft Section 2 Phases 1 U and Ashcroft Section 1 Phase 8 2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON Highway/Street Covered Bridge Road Latitude 35.6646 Longitude `78.4322 I Approximate date land -disturbing activity will commence: March, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential S. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32.68 6. Has an erosion and sediment control plan been filed? Yes No Enclosed 7. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name N ick MCKeel E-mail Address nick.mckeel@providence.construction Telephone 919-429-0245 cell # 919-429-0245 Fax # 8. Landowner(s) of Record (attach accompanied page to list additional owners): Ashcroft Partners, LLC 919.813.0123 Name 114 W Main Street Telephone Same Fax Number Current Mailing Address Current Street Address Clayton NC 27520 Same City State Zip City State Zip 9. Deed Book No. 05318 Page No. 0064 Provide a copy of the most current deed. Part B. 1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship the name of the owner or manager may be listed as the financially responsible party. Ashcroft Partners, LLC Name E-mail Address 114 W Main Street Same Current Mailing Address Current Street Address Clayton NC 27520 Same City State Zip City State Zip Telephone 919.901.3178 Fax Number 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone Fax Number (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: Reid Smith reid@theriverwildteam.com Name of Registered Agent E-mail Address 114 W Main Street Same Current Mailing Address Current Street Address Clayton NC 27520 Same City State Zip City State Zip Telephone 919.901.3178 Fax Number. 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. Reid Smith Type or print name SigKature Managing Member Title or Authority 1 /24/2022 Date I, 'P-ebetxo% L. Nlovyt-t'Z. , a Notary Public of the County of -5JIvisom State of North Carolina, hereby certify that PAACI . SYh1iAA 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 2-44" day of , 20 22 .aLH11p� Mp G` - w; I �O'CARY s Notary Seal v� ccy V My commission expires IC-13- 02 ,_ PU��'� ,ar