NCC221732_FRO Submitted_20220505

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 Portofino - Phases 12A(Lots 457-466)
2. Location of land -disturbing activity: City or Township Wilders
Highway/Street Syracuse Drive Latitude 35.6303 Longitude-78.3612
3. Approximate date land -disturbing activity will commence: Winter 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: $ 1,980 . 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 George Young E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mattamy Homes LLC
Name Telephone Fax Number
11000 Regency Parkway, Suite 110 1)6*6 !!! wlC so.�t 1 i 4
Current Mailing Address Current Street Aiddrets
Cary, NC 27518 Cary, NC 27518
City State Zip City y State Zip
10. Deed Book No. 6141 Page No. 17 � 1 17 l
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):
Mattamy Homes - George Young [e-mail]
Name E-mail Address
11000 Regency Parkway, Suite 110 11000 Regency Parkway, Suite 110
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State
Telephone [phone]
Zip City
Fax Number
State Zip

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
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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:
Mattamy Homes - George Young
Name of Registered Agent
11000 Regency Parkway, Suite 110
Current Mailing Address
Cary, NC 27518
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
11000 Regency Parkway, Suite 110
Current Street Address
Cary, NC 27518
City State
Fax Number
Zip
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.
9- - Lie k.. --Y., V I or pr t e Title or Authority
I A L1 sC Ko "�1467L-
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Date
--------------------------------
, a Notary Public of the County of u_3AtL�
State of North Carolina, hereby certify that G a C* `Z0g:3 G 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 a'7
PN, KUI►fk
N 1
SBI�bTARY
n PUBLIC �-
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day of 20
Notary
My commission expires -301. D D

TIMMONS GROUP
VISION AC•'°`"v* " ?c' OURS.
ADDENDUM —Additional Landowners of Record (Lots 460, 461, and 464)
Name: ALI 2 Farms LLC
Current Mailing Address: 442 %2 East Main Street, Clayton, NC 27520
Current Street Address: 442 %2 East Main Street, Clayton, NC 27520