NCC223952_FRO Submitted_20221130

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAU1No person may initiate any land -disturbing activity on one or more acres as covered by the 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
NORTH' CAPOIMIA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
2. Location ofland-disturbing activity: Jurisdiction Wake County (Wake Co. o,Municipality)
Highway/Street Wendell Blvd. Latitude Longitude
3. Approximate date land -disturbing activity will commence: Novmmber2U22
4. Type of development (residential, commercial, industrial, institutional, etc,): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 11
O. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Donahue E-mail Address [e-mail]
Telephone [phone] Qd|# Fex#
7. Landownmr(a)ofRecord (attach accompanied page holist additional ovvner ):
810-571-�O�4
VVendaU/LenueLLC dhudson@andemon-auto.n*t
Name(n) Telephone Fax orE-mail address
01U1Glenwood Ave 81O1Glenwood Ave
Current Mailing Address Current Street Address
Raleigh NC 2761 Raleigh NC 27817
City State Zip City State Zip
O. Deed Book No. 015225 Page No. 01478 Provide acopy ofthe 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):
DRB Group North C/iLLC [e-mail]
Nam* E-mail Address
3OOORDUCenter Dr. Buite202 30UORDUCenter Or..Suite 202
Current Mailing Address Current Street Address
PWorhavU|e NC 27560 Morrisville NC 27560

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:
Nome E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is o Partnership o,other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party iaa Corporation, give name and street address ofthe Registered Agent:
N/A
Name ufRegistered Agent E-mail Address
Current Mailing 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
bvrneunder oath (This form must be signed bvthe Financially Responsible Person if an individual
Or his @tbonney-in-faot, urifnot en indk/idu8|, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change inthe information provided herein,
Crai0K8yrnnaD Authorized Agent
Type or print name Title or Authority
8ignGtuDe U Dote
______________________________________________________________________
Notary Public ofthe County of
��
State of North Caro|ina, hereby certify that �~ / appeared
peraonoUybefore methis day and being duly sworn acknovWed�sdUhat�he(aboveform was executed byhim.
Ot,
Witness my hand and notarial seal, this day of 2