NCC221672_FRO Submitted_20220429

=�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P::7 SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
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 Lot 60 Sanctuary
2. Location of land -disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
2609 Sanctuary Woods Lane 35.713858-78.728234
Highway/Street Raleigh Nc 27606 Latitude Longitude
3. Approximate date land -disturbing activity will commence: 5/1/22
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): .42
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry Nordan E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Future Homes by Jim Thompson Inc 919-363-4111
Name(s) Telephone
1105 Classic Rd 1105 Classic Rd
Current Mailing Address
Apex NC 27539
Current Street Address
Apex NC 27539
City State Zip City
8. Deed Book No. 18172 Page No. 2100
State
919-363-4044
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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):
Future Homes by Jim Thompson [e-mail]
Name
1105 Classic Rd
Current Mailing Address
Apex NC 27539
City State
Telephone [phone]
E-mail Address
1105 Classic Rd
Current Street Address
Apex NC 27539
Zip City State Zip
Fax Number 919-363-4044

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
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
Zip City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
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.
Jim Thompson
Type or print name
Signature
Sandra Jones
President
Title or Authority
4/14/22
Date
a Notary Public of the County of
Wake
State of North Carolina, hereby certify that Jim Thompson 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 ILA day of i 20Il
a o2
aSANDRA JONES Notary
Nota Public, North Carolina
4ake County 2/1/25
My Commission Expires My commission expires