NCC222830_FRO Submitted_20220809

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: Patchetts Branch — EC Plan for Lots 5 6 7A 8 and 9
2. Location of land -disturbing activity: County: ,Johnston City or Township:. Bentonville
Highway/Street: Joyner Bridge Road Latitude: 35.3381 Longitude: - 78.3347
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0 acres
6. Amount of fee enclosed: 1,140.00 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).
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: Mickey Lamm E-mail Address: mslamm(aDembargmail.com
Telephone: (919) Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners). -
Caliber Development Inc. [phone] _
Name Telephone Fax
2191 Vinson Road 2191 Vinson Road
Current Mailing Address Current Street Address
Clayton NC 27527 Clayton NC 27527
City State Zip City State Zip
10. Deed Book No.: 6148 Page No: 25— 27 Provide a copy of the most current deed.
Part B.
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):
Caliber Development Inc.
Name
2191 Vinson Road
Current Mailing Address
Clayton NC 27527
City State Zip
Telephone: [phone]
mslam_ m(a�embargmail.corn
E-mail Address
2191 Vinson Road
Current Street Address
Cis ton INC 27527 _
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
State Zip
E-mail Address
Current Street Address
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:
Mickev Shawn Lamm
Name of Registered Agent
2191 Vinson Road
Current Mailing Address
Clayton NC 27527
City State Zip
Telephone [phone]
mslamm(@embaramail.com
E-mail Address
2191 Vinson Road
Current Street Address
Clayton NC 27527
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). I agree to provide
corrected information should there be any change in the information provided herein.
Mickey Lamm Registered Agent Caliber Development LLC
Type or D4.0t name Title
oorr�Authority
Signature Date
ANIT# JV/ • LAMM
a Notary Public of the County of 3-04N5fa
State of North Carolina, hereby certify that AA1ckE\1 64M(A)tV C->4MM 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
10
• Seal
pub
WOO
ston GO
a I O` day of -:Y UN L
Notary
, 2022
My commission expiresNOVEWE12 30, a-aas