NCC221400_FRO Submitted_20220413

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Igo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
7WTK; County Unified Development Ordinance before this form and an scveptabie erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
VOR1t1 t.AMII INN 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 ize,11CAckle SID 1.7dr 171 17 t ? 1 ?*
2. Location of land-dlsturbing activity: Jurisdiction yri he _ (Wake Co. or Municipality)
Highway/Stree [ q�,cit Latitude11&0_ Longitude�
3. ,Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc._9&j9d±1j
5. Total acreage disturbad or uncovered (including off -site utilities and' borrow/waste
areas);_ - . 7 3 _
6. Person to contact should erasion and sediment control Issues arise during land -disturbing activity: N
Name, F-6 C jto !:� ejjLJ'_ 9-madAddress wt a✓i rt M�3 r "eS.c o wf
Tetephon® - - o R Cell # _ 21-0- 709w90a 1 Fax # . 91 o
T Landowner(s) of Record (attach accompanied page to list additional owners):
Name(s) Telephone Fax or E-mail address
Current Mailing Address Current Street Address
City statezip City state Zip
5,V A Q ttax r1h aj
8. veed Book No. Page No. Provide a copy of the most current deed.
Part B.
t, Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
corn prehensiva list of all respons'ibip parties on an attached sheet, Include requested Information):
Ravi rte4S 9�64+&S,13vi rn.5 lJ
M cd
IMP, La' 0S M4
Name F-mall Address
R3cf'o V- ce _ i
CurunntIII+ ailing Address Currant Street Address
1II e- V G.0-02-5 satme
city y� State Zip City State zip
Telephone Q1 6 - 0 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 but of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or land
Disturbance Permit:
Name r=,-mall ,wares$
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 iCertifloate of Assumed Rome. If the Financially Responsible
Party Is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number_
The above Information is true and correct tb 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 tf 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.
e �'ce !t,o-5 r, � 1 Gdui►ie,s`Sk tS
Type or print n Title or Authority
-9/
Signature
a Notary Public of the County of
State of North Carolina, hereby Certify that 1 S appeared
personally before me this day and being duty sworn acknow edg d that the above form was executed by him.
Witness my hand and notarial seal, this
'St,r =d=Of-. �
M.
Seal1G��'
8� Notary Public
Cumbeniond County
My Com 1sslloon t xpfre$
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My Commission expires