NCC222350_FRO Submitted_20220628

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
WAKICounty 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
nonrri �,� t, N;� 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 75 Camberly, Lot 77 Camberly, Lot 78 Camberly, Lot 79 Camberly, Lot 80 Camberly
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Dover Hills Drive Latitude 35.981694 Longitude
3. Approximate date land -disturbing activity will commence: 04/01/2022
-78.571442
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 3.47
N
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joe Catalano E-mail Address [e-mail]
Telephone [phone] Cell # - Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Exeter Building Co. LLC
Name(s)
900 Ridgefield Drive STE 50
Current Mailing Address
Raleigh NC 27609
City
State Zip
8. Deed Book No. 018882 Page No
Part B.
Telephone Fax or E-mail address
900 Ridgefield Drive STE 50
Current Street Address
Raleigh NC 27609
City State Zip
02598 Provide a copy of the most current deed.
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):
Exeter Building Co. LLC [e-mail]
Name E-mail Address
900 Ridgefield Drive STE 50 900 Ridgefield Drive STE 50
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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 Zip
Telephone
E-mail Address
Current Street Address
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.
Type
Sign
John Finan
Managing Member
Title or Authority
02/10/2022
Date
Gt.d-a Notary Public of the County of L J A K
State of North Carolina, hereby certify that 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 L&b' day of
JEREMY GAGE N
Nota&P_4blic - North Carolina
WJake County
My Commission Expires Apr 3, 2024 IV
'rbrva r-, 112
11
commission expires