NCC231741_FRO Submitted_20230607

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
NO N ; ,<<�� 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 1/C./OLI 31-tv
2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street l/lsLa Latitude 35.c152501 Longitude —73. Cs$8L
3. Approximate date land-disturbing activity will commence: 1-I-ZvZL
4. Type of development (residential, commercial, industrial, institutional, etc.): l2s:ct-'tI-'c.(
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): D.411
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name et/te- JoI,n-sort E-mail Address /y(c. °C rate t w ..fom horvkc.1.r..
Telephone q13.53D O 19 -7 Cell# — Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KGllci etL -brn m.t..1 rr,e- . }lct 395/S -ci 4y!-2vs sl A o4cc..).
Name(s1 Telephone Fax or E-mail address
L�73L. Tcrls lt/u,1G4,15,,k 3ov
Current Mailing Address Current Street Address
ea lc I 1-s A,./ a7 1-
City / State Zip City State Zip
8. Deed Book No. :o ' ;; Page No. /3.19 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):
1G1:i 1 WJ TVAv1 yt�3 W7'�L- r7 �G/5i7GUJ/L7��idrYt�J •
Name J E-mail Address
OL" polls Ale 201 Ste,it-30 0 r
Current Mailing Address Current Street Address
e64164.5k- /VC. a7C..(5-
City State Zip City State Zip
Telephone Cf S3o-O 1 q 7 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 Stale 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
, Lit w. /17or,pScSn rss,cie.,� , l lu5l+ Goti-oeet
Type or print name Title or Authority
�- ...� -II-LoZZ
Sin re Date
//tale
I,44/1/,7/// �[ /4 , a Notary Public of the County of
State of North Carolina, hereby certify that /ram# /rv.4/2p,1 appeared
personally before me this day and being duly sworn acknowleOged that thb above form was executed by him.
Witness my hand and notarial seal, this day of Ar , 200 TA
R� l 'Notary
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