NCC232051_FRO Submitted_20230710

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countysedimentati Unifiedn co Development be bo
COUNTY ontrol plan haveOrdinance been completedefor and this approvedform byand an Wake Countyaccepta le Department
er sion ofand
„�„ 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 Exchange at 401
2. Location of land-disturbingactivity: Jurisdiction Town of Garner
y (Wake Co. or Municipality)
Highway/Street Hwy 401 Latitude 35.675598 Longitude -78.688640
3. Approximate date land-disturbing activity will commence: 3/24/2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_ 27.7
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Cobb E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Pulte Home Company, LLC
c/o Chris Raughley [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
1225 Crescent Green Dr, Ste 250 1225 Crescent Green Dr, Ste 250
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State Zip City State Zip
8. Deed Book No. 19192 Page No. 886-891 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):
Pulte Home Company, LLC
c/o Chris Raughley [e-mail]
Name E-mail Address
1225 Crescent Green Dr, Ste 250 1225 Crescent Green Dr, Ste 250
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State Zip City State Zip
Telephone [phone] 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:
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.
C.V.r t S Za,,.45 1/kIty V P Lov„
Type or print name Title or Authority
312.‘kl �3
Signature Date
I, M 411 S/l €la e( , a Notary Public of the County of A OlA ..-
State of North Carolina, hereby certify that CA1 VI S q h E appeared
personally before me this day and being duly sworn acknowledged that th above orm was executed by him.
Witness my hand and notarial seal, this 71- day of fv 4tl/►'_VvV , 20 `L 3
--- . 2 Notary
Seal zc ., ()TAF ',Y = /
My commission expires 0 71 Z11
UBL\
' G
-9