NCC215160_FRO Submitted_20210914

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
.0 Mon.,
T No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name McNeill Burbank Lots Wendell Falls Ph9B and 12
2. Location of land -disturbing activity: Jurisdiction Marks Creek (Wake Co. or Municipality)
3
0
5
Highway/Street°ouglas Falls. Millrock Tail Latitude Longitude
Approximate date land -disturbing activity will commence: Sept 2021
Type of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site utilities and
areas):
borrow/waste
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nolan Paussa E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
CCH RDU, LLC
919-781-5225
Name(s)
Telephone Fax or E-mail address
3739 National Drive
Suite 128
Current Mailing Address
Current Street Address
Raleigh
27612
City State
Zip City State Zip
8. Deed Book No.
Page No. 939-940 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. Include requested information):
CCH RDU, LLC
[e-mail]
Name
E-mail Address
3739 National Drive
Suite 128
Current Mailing Address
Current Street Address
Raleigh NC
27612
City State
Zip City State Zip
919-781-5225
Telephone
Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
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:
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 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.
Leslie Pierce
Type or wint name �,,,
ignature
Peco struction Specialist
Title or Authority
Date
I, Ck�,rr I t k1yy< 1I a , a Notary Public of the County of
State of North Carolina, hereby certify that is ('� i Q,cc e_-_-_- appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
� II
Witness my hand and notarial seal, this Aday of t 20 Z t
N61ary
My commission expires