NCC240459_FRO Submitted_20240227

21.022
"WM 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
fine Development de be an
COUNTY sedimentationCountyUni ed controlev planlopmen haveOr beeninanc completedefor and this approvedform byand an Wake Countyaccept le Department ofand
NORTH CAROLINA 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 The Redeemed Christian Church Of God Victory Temple
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Broughton Road Latitude 35d51'54.88" N Longitude -78d25'05.42 W
3. Approximate date land-disturbing activity will commence: 2/1/23
4. Type of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.05
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adebisi Oshikoya E-mail Address bisioshikoya(ieyahoo.com
Telephone [phone] Cell# [phone] Fax# n/a
7. Landowner(s) of Record (attach accompanied page to list additional owners):
The Redeemed Christian
Church Of God Victory Temple [phone] bisioshikoya(&yahoo.com
Name(s) Telephone Fax or E-mail address
3317 Broughton Road 3317 Broughton Road
Current Mailing Address Current Street Address
Wendell NC 27591 Wendell NC 27591
City State Zip City State Zip
8. Deed Book No. 018420 Page No. 00275 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):
Adebisi Oshikoya bisioshikoyartiyahoo.com
Name E-mail Address
3317 Broughton Road 3317 Broughton Road
Current Mailing Address Current Street Address
Wendell NC 27591 Wendell NC 27591
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:
n A n1/a
Name E-mail Address
n a nfa
Cdrrent Mailing Address Current Street Address
n1 A n/A
Cify State Zip City State Zip
Telephone n/a 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:
n a n/a
N me of Registered Agent E-Fnail Address
n la n/a
C rrent Mailing Address Current Street Address
n a n/a
Cit State Zip City State Zip
Telephone n/a Fax Number n/a
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 inPmation provided herein.
ACII2btS tkl- L �4 1'��s �:-)
Type or print name Title or Authority
Signature Date
I, J( 1/ ill I"-.CiC , a Notary Public of the County of .J(}Y\f454 k,
State of North Carolina, hereby certify that 11d{'hr'5 fiS h r ko C 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 c 2-day of sec
l eMbPr" , 20 2 ?—
.' .. Nota
My commission expires &Veil/ V /Z .)G�Z 2
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