HomeMy WebLinkAboutNCC221713_FRO Submitted_20220513FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. ElementarySchool 51 Site Construction
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Holly Springs
Highway/street Woods Creek Rd Latitude 35.683889 Longitude 78.888333
3. Approximate date land -disturbing activity will commence:July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): school
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 39
2,535.00 (paid with check)
6. Amount of fee enclosed: $ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William Hartley E-mail AddresswhartleyC@wcpss.net
Telephone 919-588-3577 cell # 919-422-1867 Fax # 919-589-6347
R
Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education 919-588-3577
Name Telephone
5625 Dillard Dr, Crossroad Building 1 same
Current Mailing Address
Cary, NC 27518
City
10. Deed Book
State
17409
Current Street Address
same
Zip City
Page No.1719
State
n/a
Fax Number
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Wake County Board of Education dneter@)wcpss.net
Name
5625 Dillard Dr, Crossroad Building 1
Current Mailing Address
Cary, NC 27518
City State
Telephone 919-694-0232
E-mail Address
Same
Current Street Address
Same
Zip City
Fax Number n/a
State
Zip
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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:
n/a
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.
David Neter
Type or print name,
Signature
Chief Business Officer and Interim Chief of Facilities & Operations
Title or Authority
Date
USCeN a Notary Public of the County of Y �,�:�.
State of North Carolina, hereby certify that , I Qt 1� I (� l_ Iy �( 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 day of M01-412021
SHAM M. FERGUSON , otary
Notary Public, North Carolina
eal Wake County
My CoTigi� n Expires My commission expires ! l 2 7