NCC232947_FRO Submitted_20231004

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
ou be and
COUNTY sCedimentationntyUnified control planDevelopment have beenOrdinance completedfore andthis approveformd byand an Wake Countyacceptable Departerosionment of
NORTH CAROL]NA 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 Coldwater Springs Subdivision Phase II
2. Location of land-disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street Coldwater Springs Drive Latitude N35° 51' 18.75" Longitude W78° 29' 01.70"
3. Approximate date land-disturbing activity will commence: February 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):3.63
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bill Turner E-mail Address [e-mail]
Telephone [phone] cell# N/A Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
BPTM Development LLC 919-876-9200
Name(s) Telephone Fax or E-mail address
410 Lakestone Dr Same
Current Mailing Address Current Street Address
Raleigh NC 27609 Same
City State Zip City State Zip
8. Deed Book No.019165 Page No.00188 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):
BPTM Development LLC Bill Turner
Name E-mail Address
410 Lakestone Dr Same
Current Mailing Address Current Street Address
M+��:L•14.. dill/!
Raleigh NC 27609 Same
City State Zip City --:41;i.. Zip
919-876-9200 n/a `'';t '�%; t,.;,► r
Telephone Fax Number t
i

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.
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I, eV 4t "°-- ' S fie. , a Notary Public of the County of V V a-1(�-
State of[ North Carolina, hereby certify that V v • L. _r `r i I appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hanciaQii jotarial seal, this 1 day of J\f 0 J�v .to-Cr, 20_00
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v�;.. OTAR Y�'�% Notary
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Seal
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