NCC230718_FRO Submitted_20230317

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
V YACounty 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Project Name Grevcliff Lot 6
2. Location of land -disturbing activity: Jurisdiction wake (Wake Co. or Municipality)
Highway/Street New Light road Latitude 36.039 Longitude
3. Approximate date land -disturbing activity will commence: Feb 15 2023
-78.641
4. Type of development (residential, commercial, industrial, institutional, etc.): Res
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.458
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tom Petruccelli
E-mail Address [e-mail]
Telephone Cell # 9192914318 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
haven homes iic 9193495598 [e-mail]
Name(s) Telephone Fax or E-mail address
1116 hawk hollow lane
Current Mailing Address
wake forest nc 27587
City State Zip
Current Street Address
City
State
Zip
8. Deed Book No. ® 019249 00599 Page No. ® 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):
haven homes Ilc [e-mail]
Name E-mail Address
1116 hawk hollow lane
Current Mailing Address
wake forest nc 27587
City State Zip
Current Street Address
City
Telephone [phone] 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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State 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 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
Telephone.
State Zip
E-mail Address
Current Street Address
City State Zip
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.
chris ders managing partner
T or pri a Title or Authority
ature Date
I, �a.,...�►vel A 0i�o,r� n.r a Notary Public of the County of
State of North Carolina, hereby certify that (. 5 �4�eof �S appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
dy
Witness my hand and notarial seal, this D day of F 20
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