NCC222669_FRO Submitted_20220727

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.
1. Project Name Avalaire Phase 2
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Durant Road Latitude 35.913710 Longitude-78.631672
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 13.0
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Cameron Jones E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
cameron.jones@
Parker Propeties
[phone] terramorhomes.com
Name(s)
Telephone Fax or E-mail address
12801 Durant Road
12801 Durant Road
Current Mailing Address
Current Street Address
Raleigh NC 27614
Raleigh NC 27614
City State Zip
City State Zip
8. Deed Book No. 005064 Page No.
00692 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):
Avalaire Land, LLC
[e-mail]
Name
E-mail Address
7208 Falls Of Neuse Rd, Suite 201
7208 Falls Of Neuse Rd, Suite 201
Current Mailing Address
Current Street Address
Raleigh NC 27615
Raleigh NC 27615
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
Telephon
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 provided herein.
Type_o me Title or Authority
Signature Date
-6N' <,S a. VU t LIL�j a Notary Public of the County of zv L-kc'
State of North Carolina, hereby certify that �D��,� �2�� 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 th day of �'l�' 20 1
kit S5t J�_
MELISSA WICKSTROM Notary
Not�r� ublic, North Carolina
iNake County
My Commission Ex .res
My commission expires,
I d- q r2-'L'