NCC223645_FRO Submitted_20221025

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAUCounty 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
hnIII ,i CAROL IN'A Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A. /
1. Project Name I o r��{0A b( dt Lb t D--0
.i j J
2. Location of land-disturbin activity: Jurisdiction i Q (Wake Co. or Municipality)
Highway/Street Latitude '�8. V V 3 Longitude
— � .j�f7
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc —TA,
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ O.4 36
6. Person to contact shoulderosionand sediment control issues arise during land -disturbing activity:
Name I i� !�,Jr bLpoP. E-mail Addressf� r�.o�r�Qsh'QMC
Telepho
Cell A I q - �/o1 -1p 033 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
—) I, I -�l t t 4 -% " De, (I t q ­'iq 0 - q
Name(s) Telephone
S, Lbr ksJ
Current Mailing Address
Aqli,ok i L A-74 u�
City State ,Zip
Current Street Address
City
State
Fax or E-mail address
Zip
8. Deed Book Not ( 6i n SGj Page No.'s-'-) �� to Provide a copy of the most current deed.
Part B.
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 I &mail Address
Current Mailing AddressCurrent Street Address
f /
city State Zip City State Zip
Telephone G 1 q-i� 4 u- q 21 z 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
E-mail 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.
r
IFf U i,o0.t� 1 it/cS�o►L
Type or print 6ame Title or Authority
J6f13
Signduke Date
�/-J44'Z, , a Notary Public of the County of IAJ
State of North Carolina, hereby certify that 212 L �kYa appeared
personally before me this day and being duly sworn acknowledged fhat the above form was executed by him.
Witness my hand and notarial seal, this
LANA
THERESA A. TREFFTZS
Notary Public
Wakes arty, North Carolina
My Commission Expires
March 6, 2024
3Lday of , 20 D t
Notary
My commission expires Nryo c9 0-