Financial Responsibility Ownership Form Fillable

10 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_______________________________________________________________________2 Location of land - disturbing activity City or Township________________ ______________________ Highway Street___________________ Latitude_________________ Longitude__________________3 Approximate date land - disturbing activity will commence _____________________________________4 Purpose of development residential , commercial , industrial , institutional , etc ____________________5 Total acreage disturbed or uncovered including off - site borrow and waste areas _________________6 Amount of fee enclosed ____________________ The application fee of 50000 per acre rounded up to the next acre is assessed for the first 10 acres and an additional 250 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_________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 ____________________________________ ________________________ _________________ Name Telephone Fax Number ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City St ate Zip City State Zip 10 Deed Book No _______________ Page No ______________ 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 ____________________________________ ___________________________________________ Name E - mail Address ____________________________________ ___________________________________________ Current Mailing Address Current Street Address _______ _____________________________ ___________________________________________ City State Zip City State Zip Telephone____________________________ Fax Number_________________________________Page2 a If the Financially Responsible Party is not a resident o f 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 Cor poration , 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 indivi dual , 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 _____________________________________ _______________________________________ Type or print name Title or Authority _____________________________________ _______________________________________ Signature Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I , __________________________________ , a Notary Public of the County of _________________ State of North Carolina , hereby certify that _______________________ ______________ 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 ______ day of _________________ , 20 _______ ____________________________________ ___ Notary Seal My commission expires_ ____________________Page