NCC215161_FRO Submitted_20210914

lx�w. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=7 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAIdCounty 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 Inwood Forest
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 4331 Inwood Forest Drive Latitude 35.722 Longitude-78.668
3. Approximate date land -disturbing activity will commence: August 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 9.22 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Greenwood Homes - Raleigh, LLC e
Name GPnMP Weller III E-mail Address Geor 9 @greenwoodhomes.com
Telephone Cell # 703.856.7081 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Greenwood Homes - Raleigh, LLC - George Weller III 703.856.7081 [e-mail]
Name(s) Telephone Fax or E-mail address
1628 Hidden leaf Court
1628 Hidden Leaf Court
Current Mailing Address Current Street Address
Raleigh, NC 27606
Raleigh, NC 27606
City State Zip City State Zip
8. Deed Book No. 018421,00275918421, e9266 Page No. Provide a copy of the most current deed.
018421,00271
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):
Greenwood Homes - Raleigh, LLC - George Weller ]I] [e-mail]
Name E-mail Address
1628 Hidden Leaf Court 1628 Hidden Leaf Court
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
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
Telephone
State Zip
City
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
Signature
Title or Authority
21
Date
K . VltC( J� a Notary Public of the County of W (i-Y-(--
State of North Carolina, hereby certify that i t;�UeC�� �') , Lj (Q_a ) V � appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand Mg notarial seal, this _day of r{�C � l L 20 0�
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