NCC222451_FRO Submitted_20220708

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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.
1Project Name Norwood Ridge Lots 8, 10, 11, 13, 16 & 17
.
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Lot 8: 35.938848 Lot 13: 35.939968 Lot 8:-76.657476 Lot 16: -78.654676
Norwood Ridge Drive / Lot 10: 35.938856 Lot 16: 35.941115 of 10:-76.656049 Lot 17:-78654611
Highway/Street Canyon Crest Court Latitude Lot 17: Longitude�ol13:-i5s55510
3. Approximate date land -disturbing activity will commence: 7/15/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 5.426 Acres (236,369 SF)
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Mathena
E-mail Address [e-mail]
Telephone Cell # 919-616-9534 Fax #
7. Landowner(s) of Record (attach accompanied
page to list additional owners): (Lots 10, 11, 13, 16 & 17)
Arcaterra Land LLC
919-606-6587 [e-mail]
Name(s)
Telephone Fax or E-mail address
8540 Colonnade Center Dr., Ste 105
8540 Colonnade Center Dr., Ste 105
Current Mailing Address
Current Street Address
Raleigh, NC 27615-3052
Raleigh, NC 27615-3052
City State Zip
City State Zip
8. Deed Book No. 18575 Page No. 1986 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):
Blue Heron Signatures Homes LLC
[e-mail]
Name
E-mail Address
8540 Colonnade Center Dr., Ste 103
8540 Colonnade Center Dr., Ste 103
Current Mailing Address
Current Street Address
Raleigh, NC 27615-3052
Raleigh, NC 27615-3052
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
Telephone,
State
E-mail Address
Current Street Address
Zip 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 pro ided�here'i`n.
Jason Mathena
T e or print name Title or A hority
G/3 0 /2 2-
Sidnature I Date
I, b oxt"L A N[CsY- 4A- , a Notary Public of the County of WcAL(_
State of North Carolina, hereby certify that -1(XSbh k'AokV4%.cv-%a 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 3c) day of 1uy�'t_ 120 22
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Notary
My commission expires O �i' 12 20 Z3,

ATTACHMENT I
Norwood Ridge Lots 8, 10, 11, 13, 16, 17
Additional Land Owners of Record: (Lot 8 only)
Evan Stiegel &
Manjula Nagaraja 412-716-9661 & 919-352-2548
[e-mail] &
[e-mail]
Name(s) Telephone Fax or E-mail address
401 Latimer Rd 401 Latimer Rd
Current Mailing Address
Raleigh, NC 27609-5905
City
Deed Book No. 019024
State Zip
Page No. 01647
Current Street Address
Raleigh, NC 27609-5905
City State Zip
Provide a copy of the most current deed.