NCC223993_FRO Submitted_20221202

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAMNo 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!H CAROI.,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 Nacre �OW CF ,0 7"7`
2. Location of land -disturbing activity: Jurisdiction
y (Wake Co. or Municipality')
HighwayfStreetft;(o 3 P �,ftTT Latitude s `Lit , Z" A/ Longitude 78° 2(pr 3 f,�; "`W
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): L: 6 /,Q 7-) �-L
_206. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):�_5
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name I C•,' RRC ^,�­xAlo
E-mall Address fig ,C fsS GUrr►57�2Ca c.77c�n/�'rrn+�Tlt ,CDC
Telephone 9 lLI - V7 3 ~ 31 1-3 Cell # ftC9 - 3 �-3 (t 3 Fax # i` - . 6 � - 71105-
i. Landowner(s) of Record (attach accompanied page to list additional owners):
fn t S UGT't ? i �L.,C . l �-(,, i 5 -�3 )1.3 rn-rA15�f4S�Y UC7'/ �Y
Names) Telephone p Fax or E-mail address
'&?i2uxuIle
Current Mailing Address Current Street Address
City State Zip City State
Zip
8. deed Book No. O Page No.—O t9� Provide a copy of the most current deed.
Part 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):
f 4f-t S Cof4 srrsw C/n on! t,. Lt-,
Name E-mail Address
Current {hailing Address Current Street Address
N C-, a s?t
City State Zip City State
Zip
Telephone i 3 ~ _& 13 Fax Number

2. (a) If the Financially Responsible Marty 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:
9 - __ __ 77VA�114 _ l ,Rt S r� ��aJc �q/C , r.'Or'-►
Name of Registered Agent E-mail Address
U&)4L04ft, raw Qk_
Current Mailing Address
Current Street Address
t44 i�" NC- q ?6t-7
City State Zip City
state Zip
Telephone 101 --to-13 3113 Fax Number 9 19 -` S 6Z - ?t6 ;"
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This farm 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.
Type or print name _ Title or Authority
3 6� 2C3G
Signature pate
a Notary Public of the County of 1) U"," � -
State of North Carolina, hereby certify thatC. appeared
personally beforemethis day and being duly sworn acknowledged that the above form was executed by him.
_N
,iHisni IiiNiH,i
rihye nc .01 seal, this day of /—f ca'r,, f- , 2g 2
V
z Notary
Seal
My commission expires