NCC230610_FRO Submitted_20230307

lw�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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 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 Carriage Farm Subdivision
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Pagan Rd Latitude 35.62012 Longitude-78.65813
3. Approximate date land -disturbing activity will commence: October 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):,12.18 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dennis Cyrus E-mail Address [e-mail]
Telephone [phone] cell # Same Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Carriage Farm Development LLC
n/a
Name(s)
Telephone Fax or E-mail address
1151 Tarboro Rd
Same
Current Mailing Address
Current Street Address
Youngsville NC 27596
Same
City State Zip
City State Zip
18814
1865
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):
Carriage Farm Development LLC
[e-mail]
Name
E-mail Address
1151 Tarboro Rd
Same
Current Mailing Address
Current Street Address
Youngsville NC 27596
Same
City State Zip
City State Zip
Telephone [phone]
Fax Number n/a

. � a) If the Financially Respo nsVe Part} is not a resident of Wake Coority, identify a designate# agent in
Wa ke C o u rity to rece ive any notice, p rooess, plead i ng in a ny action o r legal proceed i ng ari si ng oar t of a n y
matter relating to the Wake County Erosion and Sedimentation Control Ordinance andlor Land
Dist, rba n Permit:
Jon Frazier
Name
F10 Box 91727
Current Marling Address
Raleigh NC
City state Zip
Telephone l . 10.1 51
jf razie rCeDf Imeng ineeririg. o
E-mail Address
8951 Harvest Oaks Dr. Ste 205
u rre nt Street Add re s s
Raleigh NC 27815
City -State Zip
Fax Nurnber
(b) If the Financially Responsible Party is a Partnership or other person engagGng iri business under an
assumed na rr e, attach a copy of the Certificate of Assumed N2Me. If the Financially Responsible
Pa rty i s a Corpo rat -Ion, g i ire na,m a and street add ress of th a Flag i ste red Agent;
David M. Cyrus
Name of Registered Agent
1151 Tarboro Rd
Current Mailrfig Address
o u ngsvil e NG 7715f.
City
E-mail Addfoss
C u rrlert Street Ad d ress
tate Zip ity
Te Iephon a Fax Number
ta#e 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 roust he 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 charge En the information provided herein.
David M. Cyrus
Type or print name
mature
Member Manager
Title or Authority
mil37 _
Date
1�anr)Q�n AL � Cd f k ia Not. ry Fu b I i c of the Cou my of
Mate of North Carolina, hereby certify thatLr Ld M
ap pea red
personally before me this day and being duly sworn acknouw+ledged that the ad ve form was executed by hire,
Witness my hard and notarial seal,
Flt� day of c , 2o
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A A? -S IV atar`Y,
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Seal C .
{ My commission -expires
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