NCC230869_FRO Submitted_20230329

=�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P::7— SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
NOR Ii (AR01 INA 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 Willow Landing Lot 66
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 1421 Willow Landing Way
Latitude -78.694 Longitude 35.579
3. Approximate date land -disturbing activity will commence: 3/13/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.629
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jimmy Gaskins E-mail Address [e-mail]
Telephone [phone] Cell # 919-868-5391 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KB Home Raleigh -Durham, Inc 919-768-7988
Name(s) Telephone
4506 S. Miami Blvd., Ste. 100 Same
Current Mailing Address Current Street Address
Durham NC 27703
I✓
City State Zip City
Deed Book No. 019148 Page No. 01959
N/A
Fax or E-mail address
State Zip
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):
KB Home Raleigh -Durham, Inc. [e-mail]
Name E-mail Address
4506 S. Miami Blvd., Ste. 100 Same
Current Mailing Address Current Street Address
Durham NC 27703
City
Telephone.
State
919-768-7988
Zip City
Fax Number N/A
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:
Doug Schwartz
Name
1405 Willow Landing Way
Current Mailing Address
Willow Spring NC
City State
Telephone [phone]
[e-mail]
E-mail Address
Same
Current Street Address
27592
Zip City State Zip
Fax Number N/A
(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 State
Telephone
E-mail Address
Current Street Address
Zip 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.
Doug Schwartz
Type or print name
Division President, KB Home Raleigh -Durham, Inc.
Title or Authority
"T�_� �Z=K 3 -,I • Z3
Signature Date
Ia Notary Public of the County of
State of North Carolina, hereby certify that 10C'„c. 4:�- \YNWC.rA'L appeared
personally before me this day and being duly sworn acknowlbdged that the above form was executed by him.
Witness my hand and notarial seal, this -)\`^day of i\q*�`. 20—h—
�E:RIN N POLLOCK
NOTARY PUBLIC
Johnston County- \
North Carolina Notary
Nl$&Ammission Expires June 17, 2024 r—�
My commission expires)'na,, \1_ro On,