NCC223267_FRO Submitted_20220919

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
WAKECounty 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
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 Perry Farms Lot 52
2. Location of land -disturbing activity: Jurisdiction Wake Forest (Wake Co. or Municipality)
Highway/Street Sam Ct• Latitude 35.9508 Longitude -78.4559
3. Approximate date land -disturbing activity will commence: September 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): 0.36
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan Perry Email Address [e-mail]
Telephone [phone] Cell # 919-291-0777 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners).
ICG Homes, LLC 919-876-5802
Name(s) Telephone
4020 Wake Forest Rd. Ste. 306 Same
Current Mailing Address
Raleigh NC
City State
8. Deed Book No 18687
Part B.
Current Street Address
27609
[e-mail]
Fax or E-mail address
Zip City State Zip
Page No. 1 562 Provide a copy of the most current deed.
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):
ICG Homes, LLC [e-mail]
Name E-mail Address
4020 Wake Forest Rd. Ste. 306 Same
Current Mailing Address Current Street Address
Raleigh NC 276M
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 provided herein.
Ryan Perry
KTJ
.-
. sill ••-
Holly W. Brazell
Manager
Title or Authority
8/29/22
Date
a Notary Public of the County of Wake
State of North Carolina, hereby certify that Ryan Perry 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 29thday of August 2022
W .....B,R, n'
TA .. �a ys Notary
My commission expires 8/21 /26
A Gr,U
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