NCC223839_FRO Submitted_20221117

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
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
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 Townes at Carlton Pointe Lots 26 27 28 29 30 31
2. Location of land -disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street Jamescroft WaV Latitude 35.906904 Longitude-78.478060
3. Approximate date land -disturbing activity will commence: 12/1 /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):_0.246
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Colleen Cunningham E-mail Address [e-mail]
Telephone Cell # 919-740-1935
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Brandywine Homes, Inc.
Name(s)
PO Box 910
Current Mailing Address
Wake Forest, NC 27588
City State Zip
Telephone
732 Reserve Estates Dr.
Current Street Address
Wake Forest, NC 27587
City
State
[e-mail]
Fax or E-mail address
Zip
8. Deed Book No. 19136 Page No. 2503 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):
Colleen Cunningham [e-mail]
Name E-mail Address
same as above
Current Mailing Address
City
same as above
Current Street Address
State Zip City
Telephone [phone] Fax Number
State
M

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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax Number.
State Zip
(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:
Ii-,A
Name of Registered Agent E-mail Address
Current Mailing Address
City
Telephone
Current Street Address
State 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.
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I, ._.�� � , a Notary Public of the County of W-9_,
State of North Carolina, hereby certify that he-e_n /V 1 �_ V1c� 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 day of ✓�/4U`�M" /�- 20 Z
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