NCC231679_FRO Submitted_20230608

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
_ SEDIMENTATION POLLUTION CONTROL ACT
Noperson mayinitiate anyland-disturbingactivityon one or more acres as covered by the Wake
WAKECounty Unified Development Ordinance before this form and an acceptable erosion and
7 C O U N T Y sedimentation control plan have been completed and approved by Wake County Department of
il 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 a/LjblY19 i
(Wake Co. or Municipality)
2. Location of land-disturbing activity: Jurisdiction �r
Highway/Street S"BOtt /Vtr t,2,P ad .atitude Longitude
3. Approximate date land-disturbing activity will commence: 0
Cb 4. Type of development(residential, commercial, industrial, institutional, etc.): �1 ��1
5. Total acre^- r4icti irked or uncovered (including, off-site utilities and borrow/waste
areas): -0(::L, ,,
6. Person toto contact should erosion and sediment control issues arise during land-disturbing activity:
Name `77?-* - )ell b e E-mail Address .` 1 c.."x 'to"
Telephone I (ti—42 2" - ,t, Cell# Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
Vi2C1 j le ' ' efc.� elIG1-oqt--02vZ
Name(s) �� Telephone Fax or E-mail address
(.Ito Vectevicrei Cr
Cu ent Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No._ 0 I-Ib` 1 Page No._0 L17'1 _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):
KCO el 7 U L1t(G�df hi/ ��' �►r r� Y�GL`tid�► li, t+")04... L-t
Name E-mail Address
(AY) ��e,� C1 ---5CA4L.._ —
Curxnt Mailing AA.-
n / i �j Current Street Address
ki i(in/�/1.- c) ! 1, 7f- se,.yke -
City r State Zip City State Zip
Telephone el lei 42 Z `Q�7 I I Fax Number
0
i I

I2� (a) If the Financial)
Wake Coun y Res
ty to re possible Party is not a resident of Wake County, identify a designated agent in
matter relatin ceive any notice, process, pleading in any action or legal proceeding arising out of any
Disturbance Permit:the Wake County Erosion and Sedimentation Control Ordinance andlor Land
ermit: tilii
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:
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.
St-" Ni ) ` e P�� tl k CfeZ `1 r"U L I G YI
Type or print name Title or utho ity
ID 1Iz2,
Signature Date
I, )y'._v;s L.vece , a Notary Public of the County of W0.Ke.
State of North Carolina, hereby certify that ve N K .. II 1�atY appeared
personally before me this day and being duly sworn acknowledged that the above form vUtis executed by him.
Witness my hand and notarial seal,th•is �- 6 day of 0Cte613i.Y 2012..
��`0,.des L 0 V a. ,,,,o,
,.&C s..6Cgh; ,e is Notary
Seal `�' s
x i My Commission '� My commission expires C.AO /...2-023
3 expires
3 ' 6-10.2023 ;V
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