NCC230436_FRO Submitted_20230215

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
Project Name Benson Holiday Inn Express
Location of land -disturbing activity: City or Township Benson
Highway/Street NC Hwy 242 LatitudeN350 22' 26.46" LongitudeW780 32' 28.14"
3. Approximate date land -disturbing activity will commence: December 2022
4.
5.
6.
7.
8.
9
Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.41 AC
Amount of fee enclosed: $1,520 . 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 ❑ Enclosed E
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Adam Leath E-mail [e-mail]
Telephone[phone] cell # 434-637-7235 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners)
Benson Hotel Group II, LLC 434-634-2963
Name
PO BOX 669
Current Mailing Address
Benson NC 27504
City State
10. Deed Book No. 6264
Part B.
Telephone
Current Street Address
Zip City
Page No. 6 1 8
State
Fax Number
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):
Benson Hotel Group II, LLC [e-mail]
Name E-mail Address
PO BOX 669
Current Mailing Address
Benson NC 27504
City State
Telephone [phone]
Current Street Address
Zip City
Fax Number
State
WE

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Numbel-
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Adam Leath
Type or print name
Managing Director
Title or Authority
Upon 1015122
Signature Date
-T .4
a Notary Public of the County of
State of North Carolina, hereby certify that T • appeared
personally before me this day and being duly sworn acknowledged that th bove form was
executed by him.
Witness my hand and notarial seal, this day of U, 20�--
Caria W. Beasley NotarL 6a, I ,I
Notary Public y
Johnsf(Se0bunty NC
My Commission Expires� My commission expires-)' v�l.

Benson Holiday Inn Express — Additional Landowner
Name: Leath Co., LLC
Current Mailing Address: PO BOX 669, Benson, NC 27504
Telephone: [phone]
Fax Number: N/A
Current Street Address: N/A
Deed Book No.: 06342
Deed Page No.: 0724