NCC232963_FRO Submitted_20231002

leMill WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
7E,"----
AKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
UNTY sedimentation control plan have been completed and approved by Wake County Department of
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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 Old Bunn Rd.Subdivision
2. Location of land-disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street Parks Village Latitude 35.837659 Longitude-78.296999
3. Approximate date land-disturbing activity will commence: 1/7/2023
4. Type of development(residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):7.47
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kim Mulder E-mail Address kmulder(cildavidsonhomesllc.com
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
BC Joyner LLC BNelsonadavidsonhomesllc.con BNelson( davidsonhor
Name(s) Telephone Fax or E-mail address
336 James Record Rd.SW 1903 North Harrison Ave.,Ste.200
Current Mailing Address Current Street Address
Huntsville,AL 35824 Cary,NC 27513
City State Zip City State Zip
8. Deed Book No.019221 Page No.01781 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):
Davidson Homes, LLC kmulder( davidsonhomesllc.com
Name E-mail Address
1903 North Harrison Ave.,Ste.200 1903 North Harrison Ave.,Ste.200
Current Mailing Address Current Street Address
Cary, NC 27513 Cary, NC 27513
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.
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Type ., ri e Title or Authority
Signature Date
I, &hail ,),/pai , a Notary Public of the County of we,LKe.
State of North Carolina, hereby certify that '13r`cLA f"1 O{'1 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
myQ n,�!� day of_SAjsto 4 , 20 Z5
Witness hand and notarial seal,this „/(i
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Howell
NOTARY PUBLIC My commission expires1'25-9,,;t r 2 7 Z02(e
Wake County
North Carolina
MY Commission Expires December 27,2026