NCC223569_FRO Submitted_20221014

TOWN OF KNIGHTDALE 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 Town
of Knightdale Unified Development Ordinance before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A. 11 II I 1. Project Nameo` �z��M M ��-� f h �?Oks����� a+nci�5� ��
2. Location of land -disturbing activity: I v vV h L i r- j+5 ATown Limits or ETJ)
Highway/StreetVAAv- pond INa4 Latitude 35. 14-+L '.3 Longitude - +e.
3. Approximate date land -disturbing activity will commence: A J C nnyl T J Y og.S t iol2.
4. Type of development (residential, commercial, industrial, institutional, etc.): �Sl d-`vt -i of 1
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): I INw�
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name VS-Hrn 4-1.0%+On E-mail Address Jyjfih 6 ca+on(? lnhVIor 4j- orl
Phone # [-131J Cell # (131L) utfq - 0555
Landowner(s) of Record (attach accompanied page to list additional owners):
9.®-P 0>~N LotS L1t,1L014 3jbU jnt,d�a@ grASSIAK�
Name(s) Telephone E-mail address (-,A f i Ir a l. Got -
Current Mailing Address
cva-t,l-on iV UUl02
City v State Zip
kI I
Current Street Address
%% it
City
State
Zip
8. Deed Book No. 10 0 0 Page No. b ( I LP 4 Provide a copy of the most current deed.
0 1-941
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide
comprehensive list of all responsible parties on an attached sheet. Include requested information):
N 8� o ry ��to✓� of
C. H 4 C r&l.- I -wv i o -�- . G o ri
Ibn
Name -mai Address
$�0� �1X FoyKj �Qad forvri a-rV +-f- 101- «
Current Mailing Address Current Street Address
_?_ a.Q� � N c DU 15
City V State Zip
Phone # 01101 - boo ' 13 y U
m
City
State
Zip

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 Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone #
(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:
L
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone #
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.
�� C.. L- (�- �-,- MBA 1�
Type or print name Title or Authority
q1I Iti2
Si
1
t✓/ L► A a Notary Public of the County of L JO kP
State of North Carolina, hereby certify that ��xcq (' LQ�JiS appeared
personally before me this day and being duly sworn ackne,41iledged that the above form was executed by him.
Witness my hand and notarial seal, this day of _SC1k-A10-t-e- 20 .ate
��`,pTAip•,?�d'% Notary
� Seal
My Comm. Exp. n My commission expires
11/23/2024 c
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