NCC230056_FRO Submitted_20230111

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.
1. Project Name 408 Bethlehem Road Residence
2. Location of land -disturbing activity: ETJ (Town Limits or ETJ)
Highway/Street Bethlehem Rd Latitude 35.783 Longitude-78.490
3. Approximate date land -disturbing activity will commence: November 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): 1.43ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Vargas-Valadez
E-mail Address Danielvv Q'@att.net
[phone]
Phone # cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Daniel Vargas-Valadez
[phone] [e-mail]
Name(s)
Telephone E-mail address
113 Meadows Circle
113 Meadows Circle
Current Mailing Address
Current Street Address
Knightdale NC 27545
Knightdale NC 27545
City State Zip
City State Zip
18234 328
8. Deed Book No. Page No.
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):
Daniel Vargas-Valadez [e-mail]
Name
113 Meadows Circle
Current Mailing Address
Knightdale NC
City State
Phone # [phone]
E-mail Address
113 Meadows Circle
Current Street Address
27545 Knightdale NC 27545
Zip City State Zip

2- (a) 11 the Ftnww&My ResportM" Party is not a resident of Wake County, identify a designated agent in
Wake C u* fo nKerve arty notice. process_ pisedkV in any action or lapel prooeeding ansuxq out of any
..011 r reiatlrtiq to the Town of KneNclale Emsior► and Sedimentatm Con" Ordinance andfor
Law Dautarroe Pefmr;-
N/A
Name E-mail Address
Current MO&V Address Current Street AddresS w
City State Zip Cats State Z1
(bi If the Financially Responsible Party is a Partnership or other person engaging in business under an
aswmed name. Mb h a copy of the CefWkAgo of AssumW Nam. If the Ftnancially Responsible
Party 13 a COMOrXbM. give name and strut address of the Registered Agent
NIA
Name of Regisiarad Agent
CWTth-nt Marling Ao&ers
Clay State Zip
Phone #
E-mad Addres.3
Current Street Address
Cary State 23p
The at)o►+e information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must he signed by the Financially Response Person d an individual
or his attorney -art -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.
Daniel Vargas-Valadez Owner
Type or print name
Title or Authority
i�7t•! f�l�% s+j re". Z � I2' J2 �L
�iiinm= Date
, $ Wwy Public ai the County of
Sidi, of North Carolina. hereby certify that bo4letY o r ] -ez a w
PW*Onl* ►befare me this day and being duly slZom acknowtedgd th he above form was executed by him.
Wrtrw#s mY trend and notarial Seel. this 2 S day of M r e (' .20 - -
uk_*1"J r. V y—
L,A4l1AN P WAL.fCEA
NOT6& PUBLIC !�#`y
WAKE COUNTY, NC M commission e
M OWm,^ Wt kxWr" 07-11.202i y re _