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HomeMy WebLinkAboutNCC233495_FRO Submitted_20231201 JOHSTON 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: Spring Branch — EC Plan for Lot 55 2. Location of land-disturbing activity: County: Johnston City or Township: Elevation Highway/Street: Winterwood Dr Latitude: 35.4920 Longitude: - 78.5602 3. Approximate date land-disturbing activity will commence: October 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.4 acres 6. Amount of fee enclosed: $ 100.00 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 lot plans are $100 per lot. 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: Matthew Norris E-mail Address: mattnorris1985( yahoo.com Telephone: (910) 892 4345 Cell: (910) 890 4321 Fax: (910) 892 1163 9. Landowner(s) of Record (attach accompanied page to list additional owners): TMD Residential Properties, LLC (910) 892 4345 (910) 892 1163 Name Telephone Fax Post Office Box 727 108 Commerce Drive Current Mailing Address Current Street Address Dunn NC 28335 Dunn NC 28334 City State Zip City State Zip 10. Deed Book No.: 6394 Page No.: 274-276 Provide a copy of the most current 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): TMD Residential Properties, LLC mattnorris1985( yahoo.corn Name E-mail Address Post Office Box 727 108 Commerce Drive Current Mailing Address Current Street Address Dunn NC 28335 Dunn NC 28334 City State Zip City State Zip Telephone: (910) 892 4345 Fax (910) 892 1163 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: Matthew H. Norris mattnorris1985(c�yahoo.com Name of Registered Agent E-mail Address Post Office Box 727 108 Commerce Drive Current Mailing Address Current Street Address Dunn NC 28335 Dunn NC 28334 City State Zip City State Zip Telephone (910) 892 4345 Fax Number (910) 892 1163 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. Matthew H. Norris President, TMD Residential Properties, LLC Type or ri t name Title or Authority Si ature /4/5/ZOZL3 Date II ciploillgtoI, 5i-arr C��i� ! • i,��� , a Notary Public of the County of T.4„y��n �.Alt State of NortJ�'°Carolina, hereby chat , Li-JJvw U. /I/' .. appeared personally tZfore me4biaigpy and taming duly sworn acknowledged that the above form was executed byZim. f Witness my and nofgfG seal, i S day of 01 tc h , 2023 scA ie/i Cpv vt`tN.NN h tI-Al Notary Seal My commission expires 03/7ps"/)`1