NCC231023_FRO Submitted_20230414

OP. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP 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
TY
WAKE
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 N/A in the blank.)
Part A.
1. Project Name Franklin
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Lattyes Lane Latitude 35.969890 Longitude-78.693780
3. Approximate date land-disturbing activity will commence: January 15, 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.35
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Trey Behrendt E-mail Address [e-mail]
Telephone Cell# 910-263-9753 Fax#
7. Landowner(s) of Record(attach accompanied page to list additional owners):
John and Rachel Franklin 919-758-0993 rachel.franklin09@gmail corn
Name(s) Telephone Fax or E-mail address
500 Saint Albans Drive, Unit 414
Current Mailing Address Current Street Address
Raleigh, NC 27609
City State Zip City State Zip
8. Deed Book No.18518 Page No.1326 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):
Distinctive Remodeling, LLC Trey©distinctiveremodeling.com
Name E-mail Address
1228 United Drive
Current Mailing Address Current Street Address
Raleigh NC 27603
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 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
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.
E e asanave President-Distinctive Remodeling
Ty t na adezititei
Title or Auth rity
I 5 I Q `3
Signature Date
I, I .LiiS.�C► M MA'T ier/a Notary Public of the County oft �—Z-�
State of North Carolina, hereby certify that E elVJ Cli.d 1 - &S kr CO/L 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 5 day of V C,h 1A At f, 20 2-3
Notar
Seal
My commission expires ELISSA MONTGOMERY
NOTARY -I:
LEE COUNTY,NC
My Commission Expires 1-22-2023