NCC240153_FRO Submitted_20240122

VW WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
. `; SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
ir
WAKE County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY isedimentation control plan have been completed and approved by Wake County Department of
NOaTN CARp11NA 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 2841 EDGEMONT ROAD
2. Location of land-disturbing activity: Jurisdiction wAKE COUNTY (Wake Co.or Municipality)
Highway/Street EDGEMONT ROAD Latitude 35°50'58"N Longitude 78°24' 16"W
3. Approximate date land-disturbing activity will commence: AUGUST 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): 3.0 ACRES
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name DARLENE LUMPKIN E-mail Address [e-mail]
Telephone [phone] Cell# _ Fax# [phone]
7. Landowner(s)of Record(attach accompanied page to list additional owners):
•GHM HOMES, INC. [phone] [phone]
Name(s) Telephone Fax or E-mail address
5000 CLAYTON ROAD 3912 FAYETTEVILLE ROAD
Current Mailing Address — Current Street Address
MARYVILLE TN 37804 RALEIGH NC 27603
City State Zip City State Zip
8. Deed Book No. 18878 Page No.989 _ 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 Gst of all responsible parties on an attached sheet. Include requested information):
OHM HOMES, INC. _ [e-mail]
Name E-mail Address
5000 CLAYTON ROAD 3912 FAYETTEVILLE ROAD
Current Mailing Address Current Street Address
MARYVILLE TN 37804 RALEIGH NC 27603
City State Zip City State Zip
Telephone[phone] Fax Number(919)772-8572

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:
DARLENE LUMPKIN [e-mail]
Name E-mail Address
3912 FAYETTEVILLE ROAD
Current Mailing Address Current Street Address
RALEIGH NC 27603
City State Zip City - - - State Zip
Telephone [phone] - Fax Number [phone]
(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
DARLENE LUMPKIN [e-mail]
Name of Registered Agent E-mail Address
3912 FAYETTEVILLE ROAD 3912 FAYETTEVILLE ROAD
Current Mailing Address Current Street Address -
RALEIGH NC 27603 RALEIGH NC 27603
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
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.
DARLENE LUMPKIN _ GENERAL MANAGER
Type or print name Title or Authority
c I��'aJl DA A-IL- ( V5?Signature D
Date
•
I, /t'/161 a, L Va s u,e 2 , a Notary Public of the County of �GLFc-tom
State of North Carolina, hereby certify that ba.r Gv}� Lamp appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of USE' 20 /-3
,
MELINDA L.VASQUEZ
NOTARY PUBLIC 4- f
Wake County Notary
Seal North Carolina
'My Commission Expires Jan.15,2028 /
My commission expires Q l// /7.0i�"