NCC230820_FRO Submitted_20230327

N-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
000�_00�
SEDIMENTATION POLLUTION CONTROL ACT
WAUNo 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
NORTH 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 1429 Sky Vista
2. Location of land -disturbing activity:
Jurisdiction
Wake
(Wake Co. or Municipality)
Highway/Street Sky Vista
Latitude
35.958382
Longitude -78.691788
4
5
Approximate date land -disturbing activity will commence: 3/15/23
Type of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site utilities and
areas): 1.14
borrow/waste
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kyle Johnson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7
Landowner(s) of Record (attach accompanied page to list additional owners):
Raleigh Custom Homes Inc 9193951529
Name(s) Telephone
6736 Falls of Neuse Rd Suite 300
[e-mail]
Fax or E-mail address
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No. 18104 Page No. 0871 Provide a copy of the most current deed.
Part S.
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):
Timothy W Thompson [e-mail]
Name E-mail Address
6736 Falls of Neuse Rd Suite 300
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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
Telephone
E-mail Address T
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
E-mail Address
Current Street Address
City
Telephone 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.
Type or print name
Signa e
Title or Authority
S - z- z3
Date
a Notary Public of the County of % / �c
State of North Carolina, hereby certify that / / A appeared
personally before me this day and being duly sworn acknowledbed that the Above form was executed by him.
Witness my ha%apa,notarial seal, this day of " 20 �3
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Notary
Seal ° C°
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