NCC230217_FRO Submitted_20230125

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 Community Baptist Church
2. Location of land -disturbing activity: City or Township Cleveland
Highway/Street 617 Cornwallis Latitude 35.5756 deg Longitude-78.5741 deg
3. Approximate date land -disturbing activity will commence: 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial building addition
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.6 ac
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). Individual residential lots plans are $100 per lot.
7. Has an erosion and sediment control plan been filed? Yes Z No ❑ Enclosed ❑�
P
M
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Knight E-mail [e-mail]
Telephone [phone] cell # 919-771-4643 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Community Baptist Church 919-773-3131
Name Telephone Fax Number
617 Cornwallis Road 617 Cornwallis Road
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State
10. Deed Book No. 3229
Part B.
Zip City
Page No. 248
State
Zip
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):
Community Baptist Church/Mike Knight [e-mail]
Name
617 Cornwallis Road
Current Mailing Address
Garner NC 27529
City State
Telephone [phone]
E-mail Address
617 Cornwallis Road
Current Street Address
Garner NC 27529
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:
N/A
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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:
N/A
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail E-mail Address
Current Street Address
Zip City State Zip
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.
Michael Knight
Type or print name
Signature
Pastor - Community Baptist Church
Title or Authority
Date
a Notary Public of the County of V V-1
State of North Carolina, hereby certify that LV' G e ( IG(n ( V ` appeared
personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this J
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