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HomeMy WebLinkAboutNCC230916_FRO Submitted_20230403N-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM P=7 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 NORM CAROLINA 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 Perry Farms Lot 47 2. Location of land -disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality) Highway/Street Sam Ct. Latitude 35.9503 Longitude 78.4572 3. Approximate date land -disturbing activity will commence: March 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): 0.33 6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Ryan Perry E-mail Address rperry@icghomes. corn Telephone 919-876-5802 cell # 919-291-0777 Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): Trenton Holdings, LLC 919-876-5802 permits@icghomes.com Name(s) Telephone Fax or E-mail address 4801 Glenwood Ave. Ste. 200 Same Current Mailing Address Current Street Address Raleigh NC 27612 City State Zip City State Zip 8. Deed Book No. 18687 Page No. 1562 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): ICG Homes, LLC rperry@icghomes.com Name E-mail Address 4020 Wake Forest Rd. Ste. 306 Same Current Mailing Address Current Street Address Raleigh NC 27609 City State Zip Telephone 919-876-5802 City State Zip 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 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 E-mail Address Current Mailing 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: ICG Homes, LLC/ Ryan Perry rperry@icghomes.com Name of Registered Agent E-mail Address 4020 Wake Forest Rd. Ste. 306 Same Current Mailing Address Current Street Address Raleigh NC 27609 City State Zip City State Zip Telephone 919-876-5802 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. Ryan Perry NO P11,11- Aliffirllgiff- Holly W. Brazell Manager Title or Authority 2/17/23 Date a Notary Public of the County of Wake State of North Carolina, hereby certify that Ryan Perry appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this 17th day of February 2023 VV B �,•�•`���................. 4,9 , �pTgR �� Notary 8/21 /26 ='� = My commission expires = s