NCC232967_FRO Submitted_20231004

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 Cornwallis Landing Subdivision Phases 2-4
2. Location of land-disturbing activity: City or Township Clevland Township
Highway/Street Cornwallis Road Latitude 35.637 Longitude 78.542
3. Approximate date land-disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Residential Subdivision
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 45 Ac
6. Amount of fee enclosed: $ 7,195.00 . The application fee of$330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 per acre for each additional
acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name E-mail Address
Telephone Cell # Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Clatyon Properties Group, Inc.
Name Telephone Fax Number
5000 Clayton Road Same
Current Mailing Address Current Street Address
Garner NC 27529 Same
City State Zip City State Zip
10. Deed Book No. 5747 Page No. 604
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):
Clayton Properties Group, Inc. bclark(c�mungo.com
Name E-mail Address
2521 Schieffelin Rd Suite 116
Current Mailing Address Current Street Address
Apex NC 27502
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Moore&Alphin, PLLC
Name of Registered Agent E-mail Address
3733 National Drive Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27612-4863
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 Speiran Assistant Secretary
Type or print name Title or Authority
3- 5�-
nat - 2f
igure Date
I, 4 Mberh at rk , a Notary Public of the County of wake.
State of North Carolina, hereby certify that aad rrt SWAMe' 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 544 day of / reil , 20 21
KIMBERLY DARK Notary
Notary Public, Ndrth Carolinas
Sibele County
My CoSm•`ss Expires My commission expires $'G 2'1'
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