NCC230305_FRO Submitted_20230206

N-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
.'40P f Fi (.AR01 ) Ni Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name_ M_cnnnad'g of Wendell Eallc_ParkiA/@y , ^
2. Location of land -disturbing activity: Jurisdiction _ Wendell (Wake Co. or Municipality)
Highway/Street_5941 Taulnr Road Latitude Longitude 7g-2613-,1n1
3. Approximate date land -disturbing activity will commence: Ai must 2022
4. Type of development (residential, commercial, industrial, institutional, etc.):('.()mmPrrial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name -• .. Rijuren Address -• yanbi 11 1 rAn__j iS u • com
Telephone_1 9-A.31-2ii45 Cell #. q19-A Al-2 4$ S Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Current Mailing Address
City State Zip
Telephone
Current Street Address
City
State
Fax or E-mail address
Zip
Deed Book No.--n17P87 Page No. 01486 Provide a copy of the most current deed.
Part B.
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):
:- W- .. ►i111111:
-t 72TIT. •1:11111T�;fri u • • u
Current Street Address
City State Zip
Telephone_gJg_g31-2845 Fax Number

(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:
�sA,4Aj. PIA-yS P US...uvDQ «i+•c
Name E-mail Address -�
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 9I - a1-5 aq-$_! 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
City State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
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.
Lf �114�/ �' UU/1 G_� /L L� 4 Gdx/SZ"' ✓ i'7'Uy 17l}.y.4l._.�.1rrc1;t 9tF'S U14
Type or print name T Title or Authority
Signature Date -
I, L ; 1 a Notary Public of the County of J.: 4
State of North Carolina hereby certify that 4P-p Rn '+L 121 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 41 It , 20�Z
JI STIN A LIVELY N ry
*tary Public ?
Pitt Co., North Carolina My commission expires
My Commission Expires May 6, 2024