NCC230280_FRO Submitted_20230131

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
77
SEDIMENTATION POLLUTION CONTROL ACT
WAMNo 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
NORCH CAROItVA 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
2. Location of land -disturbing activity: Jurisdiction Mnc,ic ►,1 (Wake Co. or Municipality)
Highway/Streeter 1 men1 Latitude Longitude -11r, fat)
3. Approximate date land -disturbing activity will commence: "Se nr .., np
it
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ EM
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Telephone 9lr1- J9s_ GnRc Cell # cr -r?r5 _ Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�"r &Cl r4-r�Aw.--i.wC� /f� 910-aw-i. 14 rke-l�lS. nyy�p �.,
1
Name(s) Telephone Fax or E-mail adds -C
_ri+�7�S,L SnMP
Current Mailing Address Current Street Address
CRY State Zip
City
State
Zip
8. Deed Book No. 1Q 18giv Cam` page No. cM mip Provide a copy of the most current deed.
Part B. GG
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):
1 KS(lP(®.YlM11R n+AIf eq.Q1M
Name E-mail Address
_ smww
Current Mailing Address Current Street Address
•eR. W.,
city 0 State Zip
`. ajrCL
city
Telephone - -- cs ul Fax Number
State
RE

2. (a) If the Financially Responsible Parry 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:
.Te fi-y eir4 FIG„0:1 rime
Name
Current Mailing Address
-Am 6-:mtw AJr 7UkA
City State Zip
Telephone Ej1q-Se-,4-g1 o 1_18c
TePP ft_' .mrheTt" Qtrn
E-mail Address
S%Ww
Current Street Address
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
CRY State Zip
Telephone
E-mail Address
Current Street Address
City State in
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.
126 S4-evm A s nA Me nLf-cl Ntc,,174ger-
a pri a Title or Authority
o
i a/ -7/ aaL
ignature Date
I, �-��LA ftj a Notary Public of the County of ��,1�_ `�'i[�`'�()�ie
l
State of North Carolina, hereby certify that �pnh SVCt l - 1,! (S(3r) 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
`�11�11111 U I1l1/
�� NCITAR Yp,•; _
=2'• U13LIG :C�=
„� :?ggRCH 6.24.�R �`?.