NCC240402_FRO Submitted_20240213

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
WAKECounty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
N'URIII(�RI�I 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. ,4��
1. Project Name L G r l 3 G -,, n�i' j/)/q iS 4-n is
2. Location of land-disturbing activity: Jurisdiction tVilK (,' • (Wake Co. or Municipality)
I Loner
Highway/Street Le 5 c 9 R,d - Latitude 36•0.. -g Longitude — 7?. 5 9 3
3. Approximate date land-disturbing activity will commence: rz'bwi'c ) j J
4. Type of development(residential, commercial, industrial, institutional, etc.): ,1t 3" q
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3/f O%
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name � 4- 14.+.1 al E-mail Address er o1 KOI'r,'q, 6v► Li. coiv%
Telephone q/9 . /.L O7 Cell# g/f 19/.01 7 Fax# tv//f
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�K Perim 801cl 9/4/ ? .1'/.©907 er,' o4‘.hy,),,614J
Name(s) Telephone Fax or E-mail address
mrEDE,rf P/A,e 3 m ; a
Current Mailing Address Current Street Address
C t ri NC ,� /8 C ciry ,VC a-7 18
City State Zip City State Zip C/
8. Deed Book No. / / 146 if Page No. b ''�7 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):
EP4 D.es ►9r v) lar er a4/Ps:9n iv,/1, pin
Name E-mail Address
311 rt.) r • h Piece, 117 Mr l?n
Current Mailing Address Current Street Address
Ca
C arid. ow- 775I?
City State Zip City State Zip
Telephone ( i%p ap/ -4907 Fax Number 141/1"

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:
l yrn r Op/oh/ e lPr e olKc es. vr,b v , l), ( 04,
Name E-mail Address
Tr?* - EIr,j 9lq« 31? mT EJ07 Ave--
Current Mailing Address Current Street Address
City State Zip City '! State Zip
Telephone 91 u0 . 300o Fax Number 'y 1 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:
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--
Tyr or print nam Title or Autho 'ty
/ a
Signature
Date
l J a Ja^ L J , a Notary Public of the County of (4)6(
•
State of North Carolina, hereby certify that 1 r / G ` ' 4 d appeared
personally before me this day and being duly sworn acknow!adged that the above form was executed by him.
Witness my hand and notarial seal, this / 7 day of J u1 'I u iy , 20 . '(
—21
JASON LUK
NOTARY PUBLIC Notary /
WaPP ounty, North Carolina Mycommission expires Q a / a /
My Commission Expires 09/21/24 p