NCC223728_FRO Submitted_20221103

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
WAMCounty 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
NORT t �, (711NA 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 Amber Ridge Subdivision
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Troubadour Ln Latitude 35.75331 Longitude 78.44436
3. Approximate date land -disturbing activity will commence: July 1, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Single Family Residential
5. Total acrea a disturbed or uncovered (including off -site utilities and borrow/waste
areas): 4.85-Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thomas Chalk E-mail Address [e-mail]
Telephone [phone] Cell # 919-259-0434 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Amber Partners, LLC -Richard Stockett [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
901 Paverstone Dr, Ste. F
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
8. Deed Book No. BM2022 Page No. 0871-0872 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):
Clayton Properties Group, Inc [e-mail]
Name E-mail Address
441 Western lane 2521 Schieffelin Rd Suite 116
Current Mailing Address Current Street Address
Irmo, SC 20963 Apex, NC 27502
City State Zip City State Zip
Telephone [phone] Fax Number 919-803-8524

2.} If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
%e County to receive any notice, process, pleading in any action or legal proceeding arising out of any
u
atj
C Co in
matte relating
g to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
istu
Disturba Permit:
T "I IT: I
Current Mailing Address
City
E-mail Address
Current Street Address
State N"'zip City
Telephone 1%
State Zip
(b) If the Financially Responsible Party is a Partnership "W other person engaging in business under an
assumed name, attach a copy of the Certificate of Asibved Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Reg%tered Agent:
Name of Registered Agent
Current Mailing Address
City State
Telephone,
E-mail Address
Current Street Address
Zip City State 'S.-I, Zip
IVRLIMM
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.
Adam Speiran
Type or print name
rignature
VP - Assistant Secretary
Title or Authority
6 -.1 (V -
Date
1, V-IOA6044 b" , a Notary Public of the County of W&kt,
State of North Carolina, hereby certify that A&W 'C"_ i mri appeared
personally before me this day and being duly sworn acknowledged tKat the above form was executed by him.
t�f4'
Witness my hand and notarial sea[, this day of allrVf, .20
K RNotary
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N,otary Pubift6r1h corofins
Wake Couf�tV' My commission expires
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