NCC230779_FRO Submitted_20230328

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAUNo person may initiate any land -disturbing activity on one or more acres as covered by the VVoko
Counh/ Unified Development Ordinance before this form and an acceptable erosion and
COUNTsedimentation control plan have been completed and approved byVVake Cuunty Department of
Environmental Services, Water Quality Division. (Please type or print and, if the question in not
A applicable, place NIA in the blank.)
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1- Project
2. Location ofland-disturbing activity: Jurisdiction (Wake Co. mrMunicipality)
Highway/Street ' Latitud Longitude ^?9 tv
3� Approximate date land -disturbing activity will commence: '
4� Type of development (residential, commercial, industrial, institutional,
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
are -as):
16. Person tocontact should erosion and sediment control issues arise during land -disturbing activity:
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Current Mailing Address
'Uty State Zip
Current Street Address
City
Zip
& DuedBomk 1 Provide acopy ofthe most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on anattached sheet. Include requested information):
mail Address
Name
Current Mailing Address
Current Street Address
_E it _y State Zip

2 (a) If the Financially Responsible Party is note resident ofWake Cnunty, identify a designated agent in
Wake County k/receive any notice, process, pleading inany action orlegal proceeding arising out ofany
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is u 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
State Zip City
Fax Number
State Zip
Tfie above information is true and correct to the best of my knowledgeand 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, o/ if not an indkiduo/, by an officer, director, padnar, or registered agenivAth
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change in the information provided herein.
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Date
|.a Notary Public of the County of
State of North Carodhna, hereby certify -appeared
personally before methis day and being duly sworn oknowledg*dthat the above form was executed byhim.
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VVftneosmyhand and notaha seal, this _��/__dmyof
S&tary Public
Wake Co., North Carolina
My Commission Expires March 29,2027
20
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commission expires