NCC222967_FRO Submitted_20220819

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Baylee Ridge Phase 1, Lot 75
2. Location of land -disturbing activity: City or Township Johnston Co
Highway/Street Lynch Road Latitude 35.67689 Longitude-78.32415
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.42
fi. Amount of fee enclosed: $ 100.00 . The application fee of $380.OD 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 erosion and sediment control issues arise during land -disturbing activity:
Name Adam Skidmore E-mail [e-mail]
Telephone Cell # 919-302-3751 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Robuck Homes Triangle, LLC
Name Telephone Fax Number
P.O. Box 17102 6131 Falls of Neuse Road, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27619 Raleigh NC 27609
City State Zip City State Zip
10. Deed Book No. 6301 Page No. 324-326
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):
Robuck Homes Triangle, LLC c/o Jessica Head [e-mail]
Name
P.O. Box 17102
Current Mailing Address
Raleigh NC 27519
City State Zip
Telephone [phone]
E-mail Address
6131 Falls of Neuse Road, Suite 200
Current Street Address
Raleigh NC 27519
City State Zip
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:
NIA NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone NIA
Fax Number NIA
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City
Telephone NIA
State Zip
City State Zip
Fax Number NIA
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.
Jessica Head
Type or rin# name 7
Si ure
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Treasurer of Robuck Homes, Inc.
Title or Authorit'Ki y
Zo Z Z-
Date
Jai C. Norbech Wake
a Notary Public of the County of
State of North Carolina, hereby certify that Jessica Head 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 8th
Seal
N 0 T g R Y y
p�BZ IC
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day of August 20 22
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N tary
09/26/2026
My commission expires