HomeMy WebLinkAboutNCC215571_FRO Submitted_20211007WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
Wj►.KE
County 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
NORThf CARMANA 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,
2. Location of land -disturbing activity, Jurisdiction Town of Rolesville (Wake Co, or Municipality)
Highway/StreetTsll willow Way 8Latitude 35.93 Longitude -78.47
mom way
3. Approximate date land -disturbing activity will commence; 9/112021
4. Type of development (residential, commercial, industrial, Institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2.50
6. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name Hal Perry E-mail Address halaerrvt8lremc.us
Telephone 19191865-9918 Cell # N/A Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Real Estate Marketing & Consulting. Inc. P/9" V � "! a haloenv®rems„us
Name(s) Telephone Fax or E-mail address
1200 Falls of Neuse Rd: its 102
Current Mailing Address
Ralnioh NC 27609
City State Zip
6200 Fells of Neuse Rd: Ste 102
Current Street Address
City State Zip
8. Deed Book No. 16368 Page No. 1133 Provide a copy of the most current deed.
Part B.
Person(s) or firms) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City State Zip
Telephone Fax Number N/A
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
City State Zip
Current Street Address
City
Telephone Fax Number
State Zip
(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:
W. Harold Perry
Name of Registered Agent
Current Mailing Address
City State Zip
1 aiocrr�yQ h��l9G. uS
E-mail Ad ress
Current Street Address
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 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.
Lr1'114" c/Ie. r.* %, /' Q or,#re-- ) G'fa
Type or print name Title or Authority
Sianature Date
I, c C �j R0,1r,10L , a Notary Public of the County of3O6s-k r)
State of North Carolina, hereby certify that w 1-aC�cc�� d ��r r y 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 22 day of 202
oppouONR�s
;Q-P'••°0"(AI�yC'y ` Notary
,`,� My commission expires 5-Z3 23
01.
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