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HomeMy WebLinkAboutNCC222811_FRO Submitted_20220805=�W_ WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM P=l SEDIMENTATION POLLUTION CONTROL ACT A■� No person may initiate any land -disturbing activity on one or more acres as covered by the Wake County 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 NOR Ili 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 WATERFIELD RIDGE APARTMENTS 2. Location of land -disturbing activity: Jurisdiction GARNER (Wake Co. or Municipality) 101 WATERFIELD Highway/Street RInr;F PI ACF o Latitude 35.6864 Longitude-78.5606 3. Approximate date land -disturbing activity will commence: 9/1i2n22 4. Type of development (residential, commercial, industrial, institutional, etc.): NON RESIDENTIAL 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 12 AC 6 Person to contact should erosion and sediment control issues arise during land -disturbing activity: Telephone ..(919) 828.4428 Cell # Fax # (919) 828-4711 7. Landowner(s) of Record (attach accompanied page to list additional owners). DD Garn r-W terfi Id LLC (770) 474-4345 (hazel@davisdevelopfrent.com Name(s) Telephone Fax or E-mail address 403 CORPORATE EN] ER DR. SUITE 201 SAMF Current Mailing Address Current Street Address STOCKBRIDGE GA 30281 City State Zip City State Zip 8. Deed Book No. 01g,955 Page No. 02648 h 02654 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): DID Garner-Waterfield, LLC fhazel@davisdevelopment.com Name E-mail Address 403 Corporate Center Drive, Suite 201 Current Mailing Address Current Street Address Stockbridge Georgia 30281 City State Zip City State Zip Telephone (770) 474-4345 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: Corporation Service Company Name 2626 Glenwood Ave., Suite 550 Current Mailing Address Raleigh NC 27608 City Telephone State Zip E-mail Address Current Street Address 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: Same as above. Name of Registered Agent Current Mailing Address City Telephone State Zip E-mail Address Current Street Address City State Zip 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. Vice President of Davis Development, Inc., Fred S. Hazel - n er of DD Garner-Waterfield, LLC Type or print 'pame . Title or Authority Signature -------------- ZO Z Z Date 1, "E- , a Notary Public of the County of Henry State of Georgia, hereby certify that Fred S. Hazel, Vice President of Davis Development, Inc., Manager of DD Garner-Waterlield, LLC, 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 August, 2022. Megan M Lanz NOTARY PUBLIC C.Oweta County, Georgia My Commission Expires June 13, 2025 No ry My commission expires 7wv+r 5