NCC222721_FRO Submitted_20220805

WAKE COUNTY FINANCIAL RESPONS]BILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WMUNo 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
NOR7N CRNOLINA Environmental Services, Water Quality Division. (Please type or print and, K the question is not
applicable, place NIA in the blank.)
Part A. / /, prr-5CON-
1. Project Name �0 ��`7 � (� /'
10, 5 Q-
2. Location of land -disturbing activity: Jurisdiction WU 60 (Wake Co. or Municipality)
Highway/Street ,'t SCo f (.f'cs._ Latitude 3S.17731310 Longitude—78•�ycl 89 So
3. Approximate date land -disturbing activity will commence: -/ 9/4 4. Type of development (residential, commercial, industrial, institutional, etc.): PeSICJ�-�nAJ-
"
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): e 757
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: )
Name AN,, c1c A E-mail Address MIL h Q� LA 1k We-4- heyWC5. -Z
7
Telephone,
Cell # % ft g -15-7 6 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
tJk,k Q"'� A>�cs 7/9 AX -1s7b
Name(s) Telephone
Current Mailing Address Current Street Address
Fax or E-mail address
City State Zip r1 City State Zip
8. Deed Book No. )0a 1 Page No. )00 t 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):
Name E-mail Address
P Lax 170 7
Current Mailing Address / �� ) � 6 rpp
JV C
Gity State Zip
Telephone 9/g 60%1— 11-7 6
Current Street Address
City State Zip
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
E-mail Address
Current Mailing Address Current Street Address
City State
Telephon
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:
Name of Registered Agent
Current Mailing Address
City State
Telepho
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 attomey-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.
A t? v, clo� VTe- /�i' s'
Type or 126nt name Title or Authority
Signature Date
t, s _,..r3aall H 1 &It F a Notary Public of the County of r�n Y, l ; n
State of North Carolina, hereby certify that _ A11 e r,' - C LcarK 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 Fe br kv r& , 20 2 2.
`,11111111111, 1
„�•AA Notary
a My commission expires
�'�,r'Al1COV