NCC232900_FRO Submitted_20230927

ICP.11 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
Countyseimentati Unified Development O be b
COUNTY don control plan have beenrdinance completedefor and this approvedform byand Wan ake Countyaccepta le Departmenterosion ofand
NORTH CAROI.INA 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 Willow Landing Lot 54
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 1609 Willow Landing Way Latitude -78.694 Longitude 35.579
3. Approximate date land-disturbing activity will commence: 9/22/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.737
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jimmy Gaskins E-mail Address [e-mail]
Telephone [phone] Cell# 919-868-5391 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
KB Home Raleigh-Durham, Inc. 919-768-7988 N/A
Name(s) Telephone Fax or E-mail address
4506 S. Miami Blvd., Ste. 100 Same
Current Mailing Address Current Street Address
Durham NC 27703
City State Zip City State Zip
8. Deed Book No. 019437 Page No. 01385 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):
KB Home Raleigh-Durham, Inc. [e-mail]
Name E-mail Address
4506 S. Miami Blvd., Ste. 100 Same
Current Mailing Address Current Street Address
Durham NC 27703
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Doug Schwartz [e-mail]
Name E-mail Address
1405 Willow Landing Way Same
Current Mailing Address Current Street Address
Willow Spring NC 27592
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Ste. 550 Same
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number Account#: 7227849
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.
Doug Schwartz Division President, KB Home Raleigh-Durham, Inc.
Type or print name Title or Authority
Signature ° Date
I, , a Notary Public of the County of (\pc, r.
State of North Carolina, hereby certify that Sc ..>c u c\Z appeared
personally before me this day and being duly sworn acknowlddged that the above form was executed by him.
Witness my hand and notarial seal, this a U� 'day of �e,0,e `cam , 20`)S
ERIN N POLLOCK �\
NOTARY PUBLIC b1 ri _,
Johnston County �J 1 lxhoCKl,
North Carolina Notary
Sea My Commission Expires June 17,2024
My commission expires �v.2, \1 0c3A