NCC221093_FRO Submitted_20220324

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Na person may initiate any fond -disturbing activity an one or more aces as covered by the Wake
County Unified Development Ordinance before this dorm and an acceptable erosion and
sedimentation control plan have been completed and approved by Wake County Department of
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
2. Location of land -disturbing activity: Jurisdiction _. __ l.�� �� • (Wake Co. or Municipality)
H'ghway/Street 4re � •�-- �•--,.-�� Latitude 3 � ' I6. ��'� � Lar�gi�ude_. �_�`� '`�. �� `. w
3. Approximate date land -disturbing activity will commence: A jof ► � � Z �� �
4. Type of development (residential, commercial ,' industrial, institutional, etc.): /I cs•���
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): gV
6.
76
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name .0A. Oft 4 � -- Pe. r, r n E-mail Address rr -� e- 6K'a.
Telephone
Cep! # Fax #
Landowner(s) of Record (attach accompanied page to fist additional owners):
F- df f
Name(s)
4 }
�19'AI 0/.40 on.,
Current Mailing Address
A'V& et.f 17 'C/ 'Oee,
Telephone
0
�? G
Current Street Address
,.--? 7 111
19-e- z&'I //,-? /' - " - "I t
F6X or -mail &ddress
XI/J
AW001IIIII.
.V 7/0 3
- qw- _
city I State Zip City State dip
S. Deed Book Na. 94 `'� � Page No_ �rle Provide a copy of the most current deed.
417119"W]
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).a
Ige Al j& r
A A PJr If trleA A e, .4 a,
Name E-maif-Addigss'
I � ran A� f� I't•-zp
Current Mailing A06ress'
Current street Ad6ress
/?
401 7& e4
city State Zip City State Zip
Telephone ����" �G� - a Wg 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
Current Mailing Address
City State dip
telephone
E-mail Address
Current Street Address
pity 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, gee name and street address of the Registered Agent:
e-rr
Name of Registered Agent �
/;z q -? -'�
Or
Current Mailing Address
City State Zip
Telephone- 9/9&,,4i1 -a7'�a
E-rhail Address
Current Street Address
city State Zip
Fax plumber
The above information is true and correct to the best of my knowledge and belied 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 Berson}. I agree to provide
corrected information should th re be any change ire t7inrma#ion provided herein.
4or
d r
,lei
Type or print name
Signature
11
Title or Authority
Date
Y-4 0 Illy, Public of the County of LAA114
State of forth Carolina, hereby certify #hail ?1qfh4k\ ^ P-4 ( A
personally before me this day and being duly sworn acknowledged that the abo►r
Wn Dull seal, this
"AL10
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0-T A pp os
NERO
Seal
B j.%0
P q4r�,
COL,
appeared
form was executed by him.
q.day of YYV1(C-/Lm4,-- , 20 dcZ
Notary Hf" " Ho 1 I 5`h6 "
My commission expires, LI I=L*La
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