NCC240538_FRO Submitted (2)_20240223

"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
County Unified Devedce before bo
COUNTY sedimentation control planlopment haveOr beeninan completed and this approvedform byand Wan akeaccepta County le Departmenter sion ofand
NORM l'AR()I 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.
dot
1-160- lq `I36- 4-
1. Project Name � YP S I t 14h is Res- �
2. Location of land-disturbing activity: Jurisdiction id(e.S v'I I l C, (Wake Co. or Municipality)
Highway/Street�.'Yf t MV e. Latitude 3 5,q yg Longitude -18 . 4 62
3. Approximate date land-disturbing activity will commence: V . 2 202-4
4. Type of development(residential, commercial, industrial, institutional, etc.): (CS I d en-u a-I
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 5. OL-I
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Q.C to ; )a.vi S E-mail Address -d %r s ( �olehmtn
Telephone o Cell#C1 I6 ' '491 -)I La3Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
b .Z, VA-Kw-Von I1�L I61- `T 11 - al(e3 'IL
Qvisl&ci✓h v1.Co,
Name(s) Telephone Fax or E-mail address
1iW? Call 00 Neu JJZ4 ISM-Cao(
Current Mailing Address Current Street Address
City u State Zip City State Zip
8. Deed Book No.O I�j SOS Page No.OZS L}�d2 �vide 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 .R, ✓-kr\ , INC, v-‘‘.s 1 ?dihoy-�n.Name E-mail E-mail Address
20g �a.f(son1.,v i ,SfeDo
Current Mailing Address Current Street Address
e.1 ?, `�'` A“-- 1 Lo is
City 't' IS/tatte Zip City State Zip
Telephone 9 1'/� ` ") ' al(..a3 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:
C i . CO( ��f�{)D�—
Name of RegistereJAgent E-mail Address
l Lpo m i C- . 0o
Current Mailing Address Current Street Address
?\CGQ.),i‘
A) L c e( S
City (�, ' Q State Zip City State Zip
I Telephone _ 1 - - I'A 1-4-- L-4'1 co 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.
W�� Q C
,In S "RelL Q Soo✓m vie✓
Ty or print r4 me Title or AuthoYity
etC ziaSI 202-4
Signature Date
I, (-7(it./ /Y)(TJSi`k>Cv'_ , a Notary Public of the County of rog_sup--
State of North Carolina, hereby certify that J rtC-/ 2-ef M. (U i‘ S appeared
personally before me this day and being dul sworn acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this 5 day of F64 , 20
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„voss/04, Ctn
(Po ary NOW YPUBL., My commission expires I
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