NCC230566_FRO Submitted_20230310

=�w WAKE COUNTY FINANCIAL. RESPONSIBILITY/OWNERSHIP FORM
09:!� SEDIMENTATION POLLUTION CONTROL. ACT
WAUy� No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this forth and an acceptable erosion and
COUNTY sedimentation control plats have been completed and approved by Wake County Department of
NUTU" CAM INA Bnviromental 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 1-71 tr
2. i.ocatlon of land -disturbing activity; JurisdIcdon W a Yi ee V, �r 3213 3
(Wake Co. or MunicipaliEy)
9ighwayt$tre )n,F,t,`3_ '�~ Iatittlde�nC longitude
3. Approximate date land -disturbing acttvity will commence: cr.*, 6"' -
4. Type of development (residential, commercial, industrial. institutional,
5. Total acreaue 419tUrbed or uncovered (including
areas):_ .0 #rVS off -site utilities and borrow/waste
6. Personn to contact should erasion and sediment eontfol issues arise during land-disturbing
,`activ4y:
Name '�y"r 1G kf dr d E-mail Address 0, kF iP P1,-d>! -, 4,n b &r � r ryli
Telephone/ I % d'pd7 Cell # Fax #
7- Landowrter(s) of Record (attach accompanied page to list additional owners):
Mame(s) 1 Telephone Fax or E-mail address
� l � �11 oc 1 emu.
Current Mailing Address Current Street Address '
Sfete zip City State Zip
8. Deed Book No. �
I P°GIC No, Provide a copy of the most current deed.
Part B.
I. Person(s) or firms) who are financially responsible for the land -disturbing activity (Provide a
cornprehensive list of all responsible parties on an attached sheet. Include requested information):
�K 'L7e�si n13 v:'iG
Name �/�-
E-mail Address
Pev )?ig t,-F— ss 4v i
Cu� rre Maii(ng Address Current Street Address
/ sly Zip City StatE Zip
Telephone / - Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any not'sce, 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 I -and
Disturbance Permit,
Name E-mail Address
`$1 Y %l�' �-t
Current Mailing Address
city Stale Zip
Telephone
yvr
Current Street Address
Fax Number
States
Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Fume. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Marne of Registered Agent E-mail Address �-
Current Mailing Address Current Street Address
City
Telephone
State Ztp City
Fax Number
State zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attomey-in-fact, or If not an Individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority
Signature ©ate
rn
a Notary Public of the County of a Q
State of North Caralinu, hurttby eery tEigt VC y4_61j,
personally before me this day and being duly
swam acknowledged the ab
that ove form was executed by him.appeared
i�
Witness my hand and notarial seal, this O day of
20_2
CNRf et N to&�
-
siUPHEA cc,�
Notary Pub iRUNNER My commission expires v �f 2$, ZoLq
Co, North Carolina
LWake
mmiss,on "
xpires Sept. 25, 2t724