NCC216446_FRO Submitted_20211122

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
tiVAKE
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
NOR]H (A110`,%A Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Flowers Place Subdivision
2. Location of land -disturbing activity: Jurisdiction Town of Knightdale (Wake Co. or Municipality)
Highway/Street Flowers Street
Latitude 35.78568
Longitude-78.47636
3. Approximate date land -disturbing activity will commence: 05-01-2020
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage
areas): 2.8
disturbed or uncovered (including off -site utilities and borrow/waste
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jim Middleton
E-mail Address [e-mail]
Telephone [phone] Cell # 919-625-9722
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Habitat for Humanity of Wake County 919-833-1999 [e-mail]
Name(s) Telephone Fax or E-mail address
2420 North Raleigh Blvd. 2420 North Raleigh Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27604 Raleigh NC 27604
City State Zip City State Zip
8. Deed Book No. 17139 Page No. 2072 Provide a copy of the most current deed.
Part B.
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):
Habitat for Humanity of Wake County
Name
2420 North Raleigh Blvd.
Current Mailing Address
Raleigh NC 27604
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
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 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.
Type orprintname
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Signature
Pye(; 1-"�- UGC 0
Title or Authority
74,9_ 0/ 0?e
Date
I, r [fir' (5&WS ,a Notary Public of the County of . /
State of North Carolina, hereby certify that 4I r ( Lr1d16aw A ILdm it?. 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
AMBER D WILLIAMS
Notary Pu§fit North Carolina
Wake County
My Crammission Expires
MsrCh 1 7, 2024
-`O'Y'day of JIt-/ I, , 20
Notary
My commission expires 3