NCC215315_FRO Submitted_20210930

WAKE COUNTY FI AHOIAL RESPONSIML17Y10ffNERSHIPFORM
SEDIMENTATION P LL ` ION C®NT6�OE AST
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
AKE4 County Unified Development Ordinance before this form and an acceptable erosion and
Csedimentation control plan have been completed and approved by Wake County Department of
I OUNTY Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.) , 2-j .
Part A.
1. Project Name er fe 55;t141 a� f Ada 4
2. Location of land -disturbing activity: Jurisdiction WeA T (Wake Co. or Municipality)
Highway/Street ftl�z Latitude l d °i' 6 Longitude._VI/ — ` _ A"X
3. Approximate date land -disturbing activity will commence: a' c -n�
4, Type of development (residential, commercial, industrial, institutional, etc.): _ -_ "a sa y
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):6 -
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
dr
Name E-mail Address n � 0 aA yl h f-C, qa
Telephone -%7i,x CeIE # a 70a', O * 1 Fax # ➢ — 0 -
7. Landowner(s) of ecord (attach accompanied page to list additional owners):
Narne(s) f Teleph ne Fax or E--mail address
Current Mailing Address Current Street Address
F4vedaudle �® o esaw
City State Zip City State Zip
8, Deed Book No. 15t Page No. i®_sProvide a copy of the most current deed.
Part
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):
P'IF
r a9
Name
E-mail Address
5a me
Current Mailing Address Current Street Address
City ( State Zip City State Zia
Telephone P � � Fax Number.®5— 5

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:
mil . reot 01 M f�f� "A DM 14oy1 es PJ dJ d.-,►- Ad
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephoned 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
Telephone 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 Persona 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 m Title or Authority
Z�&q----
aoLA
Signature Date
I, _ df a Notary Public of the County of. kmbLackd
State of North Carolina, hereby certify that 0►- appeared
personally before me this day and being duly sworn ac nowledged th the above form was executed by him.
Witness my hand and notarial seal, thiso
day of .2 !
,s .I Irrrrryr!
tary
S4 Notor
Q©
ElA4VC Berl no b,lc icy commission expires � o�
Co
lss�a County
Expires cCA R
1lika�