NCC222761_FRO Submitted_20220811

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
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
NOR I- I( %K0I NEnvironmental 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
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Iglesia Cristiana Renacer Church
Location of land -disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street Old Bunn Road Latitude 35.837008 Longitude-78.307490
Approximate date land -disturbing activity will commence:
Type of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 4.5 Ac.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ed Sconfienza E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Iglesia Cristiana Renacer, Inc. 919-427-6943
Name(s)
PO Box 99001
Current Mailing Address
Raleigh, NC 27624
Telephone Fax or E-mail address
0 Old Bunn Road
Current Street Address
Zebulon, NC 27597
City State Zip City State Zip
8. Deed Book No. 18256 Page No. 2073 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):
Iglesia Cristiana Renacer [e-mail]
Name E-mail Address
PO Box 99001
Current Mailing Address
Raleigh, NC 27624
City State
Telephone [phone]
Current Street Address
Zip 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
Current Mailing Address
City State
Telephone.
E-mail Address
Current Street Address
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
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I, Agsic is a Notary Public of the County of &J'z K'
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State of North Carolina, hereby certify that D946'ot appeared
personally before me this day and being duty sworn acknowledged that the above form was executed by him.
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Witness my hand and notariaL§"ivt1V',,�,' _qday of 20 e-e-
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Notary
Seal
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