NCC232050_FRO Submitted_20230710

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
DevelopmentOrdinance be ibo
COUNTY sedimentationCountyUnified control planevelopmen haveOr beeninan completedefor and th s approvedform byand an Wake Countyaccepta le Departmenter 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 401 Assemblage - Section 2
2. Location of land-disturbing activity: Jurisdiction Town of Garner (Wake Co. or Municipality)
Fayetteville Road -
Highway/Street US401 Latitude 35.676305 Longitude -78.679320
3. Approximate date land-disturbing activity will commence: Q1 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): 33.00
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Cobb E-mail Address [e-mail]
Telephone 919 - 816 - 1152 Cell# 919 - 291 - 8025 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Pulte Home Company, LLC 919-816-1100
Name(s) Telephone Fax or E-mail address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City 01932St Zip 01289 State Zip
8. Deed Book No. 019192 Page No. 00886 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 [e-mail]
Name E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone 919 - 816 - 1146 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:
Chris Raughley [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Ralgigh NC 27608 RaJeigh NC 276la
City State Zip City State Zip
Telephone 919 - 816 - 1146 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.
Chris Raughley VP of Land Development
Type or print name Title or Authority
(�lti g S• r• 23
Signature Date
I, 1 Yl t'�J , a Notary Public of the County of )f)e
State of North Carolina, hereby certify that lANI-n 1 r1\ appeared
personally before me this day and being duly sworn acknowledged that the abo a form was executed by him.
Witness my hand and notarial seal, this day of , 20 23
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Notary
Seal � % I
z. t4,0 TAR My commission expires 2I23! 21
P U B L C