NCC223958_FRO Submitted_20221130

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
2.
3.
4.
5.
6.
7
Project Dame JMS Warehouse
Location of land -disturbing activity: City or Township Willow Springs
Highway/Street Pearidge Rd Latitude 35031'14.05"N Longitude 78042'15.47"W
Approximate date land -disturbing activity will commence: Spring 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Storage
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.50 acres
Amount of fee enclosed: $ 2,280.00 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). Individual residential lots plans are $100 per lot.
Has an erosion and sediment control plan been filed? Yes ❑ No ❑ EnclosedFly��
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJMS Investment Group, LLC
E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JMS Investment Group, LLC
919-414-2255
Name
Telephone Fax Number
3229 Summer Oaks Dr
Same as Mailing
Current Mailing Address
Current Street Address
Apex NC 27539
City State Zip
City State Zip
Book No. 6085 Page No.
370
10. 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):
JMS Investment Group, LLC
[e-mail]
Name
E-mail Address
3229 Summer Oaks Dr
Same as Mailing
Current Mailing Address
Current Street Address
Apex NC 27539
City State Zip
City State Zip
Telephone [phone]
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
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:
JMS Investment Group, LLC [e-mail]
Name of Registered Agent E-mail Address
3229 Summer Oaks Dr Same as Mailing
Current Mailing Address Current Street Address
Apex NC 27539
City
State Zip City
Telephone [phone]
Fax Number
State 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.
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Type or print name
Sig re
Title or Authority
Date
S - 2H - ZD Z 2
1, M ..I u.c- ra rn e- J r. , a Notary Public of the County of
State of North Carolina, hereby certify that 'J Lr L J
personally before me this day and being duly sworn
executed by him.
k,/,3..\Le.
S h e a appeared
acknowledged that the above form was
Witness my hand and notarial seal, this Z `i day of lU1 R 20 Z �-
JERRY M VERRONE, JR
Notary Public, North Carolina Notary
10 ke Gounty
My CON Expires
December02, 2023 My commission expires DP_ c.z,.,.,L,,zr O L 7-0-L3