NCC232478_FRO Submitted_20230816

11:WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countysedimentation Unified co D be b
COUNTY ntrol planevelopment haveOrdinance been completedefor and this approvedform byand Wake Countyaccepta le Departmenterosion ofand
NOR ff,CARO!INA 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 Al o(go,li l l )c rI ( 'Q_, 'Di" (9 7
2. Location of land-disturbing activity: Jurisdiction U`J -Q---, (Wake Co. or Municipality)
Highway/Street 1-1(r abS fl 'i I k-Latitude�� � 0 119 Longitude 1-7 b ( 7(] O 5 q
3. Approximate date land-disturbing activity will commence: )(A.1(, a'7/ (9.0Z
4. Type of development(residential, commercial, industrial, institutional, etc.): QS i n&Ti;& 1
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0 '-/
6. Person to contact should erosion and sediment control issues arise duringgr ffl��and-disturbing activity:
-T /1
Name 7Q I L (e, (-C'+-�t E-mail Address+ rQt�t-47S�d✓Q e 5/10111Qs,
Telephone "1 I q- -S( -Si '7g Cell# q(q - 590 -tows- #
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Th,e I� �s l y«s 6,)min q I 998g +r -zs 1 sh(' °vs.
Name(s) Telephone Fax or E-mail address (,JIY')
CtS_ 6l 1 SI x �oK S $2 I X kYLS-Pci . 44 c o �7
Current Mailing Address Current Street Address
1'1/e 7(01 S W 0-7 6 /S
City State Zip City State Zip
8. Deed Book No. 01 q0 C1 Page Now(1)`7(,-6 7 )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):
1-11/ s -- 47)1-es &al pa_v --1-.4-41)zs Sid 1-Qk shoni-0.0-0 1717 .
Name / E-mail Address
01 18-(ar V►l klA) No a ( I okkn DV,.s-
Current Mailing Address Current Street Address
Witt/LW k ) o 1 +. hid I KY LI 101 -7
City State Zip City State Zip
Telephone q i %Li g - 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:
n sLd h 0 mks ,C� nn
Name E-mail Address , r
6�1 S'i x r tcs �vJ �5,9 I Six l=ateks < O o
Current Mailing Address Current Street Address
o�p,� Q
i\ �? /S c'� 61� C- 9- 7 G 1
ity V State Zip City v State Zip
Telephone ) � ' `t `Rp' !SS 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 informatio rovided herein.
--err 6)- 1) ���s� b►S )'St6144
Type or prin name Title or Authority
Si ature Date
I,-Th as A A - 7riz-PP-Ezs , a Notary Public of the County of (A—)04<11._.,
State of North Carolina, hereby certify that ---Tswril 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 9I -day of , 20 a 3
&.
THERESA A.TREFFTZS Notary
Notary Public
WalateRiunty,North Carolina I
My Commission Expires My commission expires If C h (P •d O
March 6,2024