NCC223107_FRO Submitted_20220907

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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
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.)
ark: A.
Patel Residence
. I Project Na
Location of land -disturbing activity: Jurisdiction Wake
Highway/street Creed moor Rd Latitude 35,921439
7/1 I2022
Approximate date land -disturbing activity will commence. -
(Wake Co. or Municipality)
Longitude-78.67821 1
Type of development (residential, commercial, industrial, institutional, etc.
Residential
Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Vaibhav Jain (VJ) E-mail [e-mail]
Telephone Cell # 919-633-0681 Fax # [phone]
Landowner(s) of Record (attach accompanied page_ to list additional owners):
BELLA VISTA DEVELOPMENT 919-414-4477
Name(s)
Telephone Fax or E-mail address
9000 Creedmoor Rd.
9000 Creedmoor Rd.
Current Mailing Address
Current Street Address
Raleigh NC
Raleigh NC 27615
City State
Zip
City State Zip
Deed Book No. 2020
Page No.
1013-10104 Provide a copy of the most current deed.
rt B.
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):
Shail Construction, LLC
[e-mail]
Name
E-mail Address
Manoj Jain
114 Tealight Lane
Current Mailing Address
Current Street Address
Cary NC
27513
CARY NC 27513
City State
Zip
City State Zip
Telephone [phone]
Fax Number919-882-9077

(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
datter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
isturbance 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
'he above information is true and correct to the best of my knowledge and belief and was provided
,y Me under oath (This form must be signed by the Financially Responsible Person if an individual
it his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
-ie�authority to execute instruments for the Financially Responsible Person). I agree to provide
opected information should there be any change in the information provided herein.
anoj Jain
print name
Managing Member
Titie or Authority
12,\
Date
-_C F pri V 0 ll-e � , a Notary Public of the County of J d h h S to K1
of North Carolina, hereby certify that M 01 h D 1 J (xl ! h appeared
ally before me this day and being duly sworn acknowledged that the above form was executed by him.
my hand and notarial seal, this -c7L—day of J W 20 a o�
My commission expires 0 i 1 Z 7 12 LP