NCC215181_FRO Submitted_20210915

WAKE 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 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
NUf1l 1-1 CA RO I_[NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1
Project Name ELIZABETH SPRINGS
2. Location of land -disturbing activity: Jurisdiction ROLESVILLE (Wake Co. or Municipality)
Highway/Street AVERETTE ROAD Latitude 35.9577 Longitude-78.4575
3. Approximate date land -disturbing activity will commence: SUMMER 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): PREVIOUSLY PERMITTED: 59.66 AC TOTAL: 66.99 AC
ADDITIONAL DISTRUBED: 7.33 AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name COREY SCHMIDT E-mail Address CSCHMIDT(cttE1 HOMES.COM
Telephone [phone] Cell # Fax #
7
Landowner(s) of Record (attach accompanied page to list additional owners):
EXPERIENCEONE HOMES, LLC 919-991-1428
Name(s) Telephone
PO BOX 5509 116 TURQOUISE CREEK DR
Current Mailing Address
CARY , NC 27512
City State
8. Deed Book No. 017035
Part B.
Current Street Address
CARY , NC 27513
Zip City
Page No. 01542
State
CSCHMIDT@E1 HOMES.COM
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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):
EXPERIENCEONE HOMES, LLC [e-mail]_M
Name E-mail Address
PO BOX 5509 116 TURQOUISE CREEK DR.
Current Mailing Address
CARY , NC 27512
City
State
Telephone [phone]
Current Street Address
CARY , NC 27513
Zip City
Fax Number
State
Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
P-_(V
Type or gri HVar 1 Title or Authority
tig'a
natu Date
I, �A•^,,,) l� ,"� a Notary Public of the County of t-a h
State of North Carolina, hereby certify that j Ado 10 W C'-'1 0w2 11 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 Ptvc v S, 1- 20 21
`a Notary
al NOTARY "Y
PUBLIC' = My commission expires - at - a-oa61
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