NCC222128_FRO Submitted_20220608

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 W�
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 CAROIINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Project Name Stoneriver Phase 1-2 Amenity Center
2. Location of land -disturbing activity: Jurisdiction Town of Kniahtdale (Wake Co. or Municipality)
Highway/Street 801 Hardin Hill Lane Latitude 35.7667140 Longitude-78.5303900
3. Approximate date land -disturbing activity will commence: Serino 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Amenity Center for Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
M
7
areas): 1.3
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jon Ford E-mail Address iford747 msn.com
Telephone
Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
AC Kniahtdale Investments. LLC [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
801 Brickell Ave. STE 2360 K1 Brickell Ave. STE 2360
Current Mailing Address Current Street Address
Miami _ _ FL. 33131 Miami FL �31
City State Zip City State Zip
8. Deed Book No. 001864: 006577 Page No. 00-E: 00703 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):
AC Knightda-le Investments- LLC - Adam Adler [e-mail]
Name E-mail Address
801 Brickett Ave. STE 2360 801 Brickett Ave. STE 2360
Current Mailing Address Current Street Address
Miami FL, 33131 Miami FL, 33131
City State Zip City State Zip
Telephone [phone] 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:
_Gaines and Co. - Georcie Grammer
Name
526 Three Sisters Road
Current Mailing Address
Kni h dalle NC 27545
City State Zip
Telephone [phone]
rznrammerCaD ainesandco.com
E-mail Address
526 Three Sisters Road
Current Street Address
Kniihtdale NC 27545
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:
Brian Pearl
Name of Registered Agent
801 Brickell Ave. STE 2360
Current Mailing Address
Miami FL 33131
City State Zip
Telephone [phone]
aadler(?P:iIobalciS•comoanies.com
E-mail Address
801 Brickell Ave. STE 2360
Current Street Address
Miami FL 33131
City State Zip
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.
Brian Pearl
Type pr t or na e
l
Signature
Melissa Charria
Authorized SK-natory
Title or Authority
1 r { 10)
Cate
, a Notary Public of the County of
Miami Dade
Florida
State of Ne�R„ hereby certify that Brian Pearl 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 8th day of April 20 22
n
Melissa Charria Q�ry
(Notary Public
` testate of Florida My commission expires 5/20/2024
Comm# HH002365
g�'� Expires 5/20/2024