NCC223063_FRO Submitted_20220830

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 C;AROLINA 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
2
Project Name HealthPark at Davis Drive
Location of land -disturbing activity: Jurisdiction Morrisville
(Wake Co. or Municipality)
Highway/Street 101 Holly Creek Road Latitude 35.82430 Longitude-78.84945
3. Approximate date land -disturbing activity will commence
M
26 August 2022
Type of development (residential, commercial, industrial, institutional, etc.): Office
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 6.32 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jay Johnson E-mail Address [e-mail]
Telephone [phone]
Cell # 919-422-6527 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Davis Drive Investment Group, LLC 919-422-6527
Name(s)
1436 Ridge Road
Current Mailing Address
Telephone
1436 Ridge Road
Current Street Address
Fax or E-mail address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
8. Deed Book No. 018948 Page No. 01005 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):
MetroProperties [e-mail]
Name
1436 Ridge Road
Current Mailing Address
E-mail Address
1436 Ridge Road
Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A
Name
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
Jay Johnson
Name of Registered Agent
1436 Ridge Road
[e-mail]
E-mail Address
1436 Ridge Road
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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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Signature Date
a Notary Public of the County of Ida
State of 40h Carolina, hereby certify that appeared
personally before me this day and being duly sworn ackn ledged that the above form was executed by him.
Witness my hand and notarial seal, this day of
Notary
Seal
t.10TAgy My commission expires_
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