NCC230769_FRO Submitted (4)_20230321

N-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l SEDIMENTATION POLLUTION CONTROL ACT
W No 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
N(,I`I t1 , \1; ,11, + 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 Cambria - Section 1
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street New Bethel Church Rd. Latitude 35.649711 Longitude-78.569104
3. Approximate date land -disturbing activity will commence: Q1 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): 1.03 AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity,
Name Chris Raughley E-mail Address [e-mail]
Telephone [phone] Cell # 919-795-9347 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Penny, Johnny Lee Heirs
Name(s) Telephone Fax or E-mail address
36 Blake Street Same
Current Mailing Address Current Street Address
Lillington NC 27546 Same
City State Zip City State Zip
8. Deed Book No. 5287 Page No. 342 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):
Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Drive Suite 250 1225 Crescent Green Drive Suite 250
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC
City State Zip City State
Telephone [phone] Fax Number NIA
27518
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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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
E-mail Address
Current Street Address
City State Zip 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.
Chris Raughley
Type or print --name
�:
Signature
VP of Land Development
Title or Authority
1. 26•Z3
Date
—,a Notary Public of the County of yvalk—
State of North Carolina, hereby certify that C1 ✓ r k t'e!j appeared
personally before me this day and being duly sworn acknowledged that the Aove for was executed by him.
Witness my hand and notarial seal, this �i� day of / 2o723
sM E
Notary
Seal
My commission expires
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