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HomeMy WebLinkAboutNCC232042_FRO Submitted_20230717 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 Mulhollem Tract 2. Location of land-disturbing activity: City or Township Johnston County Highway/Street Covered Bridge Road Latitude 35.696246 Longitude-78•337842 3. Approximate date land-disturbing activity will commence:ASAP 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.70 6. Amount of fee enclosed: $3,040 . 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 ❑ No Enclosed 111 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name James Lipscomb E-mail Addressjames@myhtr.com Telephone 919-422-4704 Cell# N/A Fax# N/A 9. Landowner(s)of Record (attach accompanied page to list additional owners): Mulhollem, LLC N/A N/A Name Telephone Fax Number 3407 Barber Mill Road 3407 Barber Mill Road Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip 10. Deed Book No.6459 Page No. 1 37 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): Mulhollem, LLC james@myhtr.com Name E-mail Address 334 East Main Street 334 East Main Street Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip Telephone 919-422-4704 Fax Number N/A 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 N/A Name E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A N/A N/A N/A N/A City State Zip City State Zip Telephone N/A Fax Number N/A (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 N/A Name of Registered Agent E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A N/A N/A N/A N/A City State Zip City State Zip Telephone N/A Fax Number N/A 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. James Lipscomb Owner Type or ame Title or Authority 3 -/od� Signature Date I, 111 I Ck ii'i. 1.1\I O1i , a Notary Public of the County of 615`00 i State of North Carolina, hereby certify that LPSwrvl 1 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 I 0 day of 1/1/\ al , 20 23 0, 1 �'' ,, RICH, j229(,(JJ/ SRO '; 1 �OTARy Notary Seal r-)1) 0 My commission expires Ul : v AVBk-\ ';�''y�STON CO