NCC230400_FRO Submitted_20230215

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
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
NORTH CAROLINA 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 Weavers Pond 5, Single Family Lot Erosion Control Plans Lots 565-638
2. Location of land -disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street Golden Plum Lane Latitude 35.861093 Longitude-78.339014
3. Approximate date land -disturbing activity will commence: Winter 2022/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 16.7 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Traver Dalton E-mail Address [e-mail]
Telephone Cell # 919-219-7927 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
DRB Group North Carolina LLC
Name(s) Telephone Fax or E-mail address
2099 Gaither Rd Ste 600
Current Mailing Address Current Street Address
Rockville NC 20850
City State Zip City State Zip
8. Deed Book No. 014947 & 019204 Page No. 01191 & 02164 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):
DRB Group North Carolina LLC rrojasAdrbgroup.com
Name E-mail Address
3 13 1 RDU Center Drive
Current Mailing Address Current Street Address
Morrisville NC
City State
Telephone
919-219-5340
27560
Zip City
Fax Number
State
Zip

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:
NIA
Name
N/A
Current Mailing Address
NIA
City State Zip
Telephone NIA
E-mail Address
Current Street Address
NIA
City State Zip
Fax Number NIA
(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:
NIA
Name of Registered Agent
N/A
Current Mailing Address
NIA
City
State Zip
NIA
E-mail Address
NIA
Current Street Address
NIA
City State Zip
NIA
Telephone NIA 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.
QIGAR-�o 4'. (l-K-kr, 1)tV(S ivyJ QY.
Type or print name Title or Authority
( ✓ I-zlr-Z3
Signature Date
I, ? J n " a Notary Public of the County of �y
State of North Carolina, hereby certify that ram; Ca'rJA0 a s _Rc�Gs appeared
personally before me this day and being duly sworn acknowledged that the aboVd form was executed by him.
Witness my hand and notarial seal, this �+� day of Cun 20
�i"SOM0000"of
.•' 010 Notary
D.f LRY ;z My commission expires
So P�U�BLIC