NCC233515_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 Lots 35— 37, 40—43. & 48
2. Location of land-disturbing activity: County: Johnston City or Township: Elevation
Highway/Street: Valleydale Dr, Blackberry Ln Latitude: 35.4939 Longitude: - 78.5590
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): 3.4 acres
6. Amount of fee enclosed: $ 800.00 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: mattnorris1985yahoo.com
Telephone: [phone] Cell: [phone] Fax: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cumberland Homes. Inc. [phone] [phone]
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
6394 150- 152
10. Deed Book No.: 6394 Page No.: 294-296 Provide a copy of the most current deed.
6394 314-316
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):
Cumberland Homes, Inc. mattnorris1985(a�vahoo.com
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: [phone] Fax [phone]

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(a�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 [phone] Fax Number [phone]
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, Cumberland Homes, Inc.
Type or rint name Title or Authority
At 5—/21 0 ot_3
Si ature Date
I, I
`1-„f L +�od��'. r��.ot`vii , a Notary Public of the County of ILIf-�r1
State of North, �r ria herebq that AA#Iov /4. N�,,f, 5 appeared
personally bear this day 1®t.eing duly sworn acknowledged that the above form was
executed byifim. ‘4OTA'4..
Witness myltd andmotaripJ seal, tie= 5 day of Uc fait/ , 2023
may?/ �!
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Seal Is-ss,�C°d,��� Notary
My commission expires i,' / , ;1,1y