NCC240618_FRO Submitted_20240301

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
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 Momington Estates Phase 4b -lot by lot
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Rock Service Station rd Latitude 35.609113 Longitude -78.668935
3. Approximate date land-disturbing activity will commence: November 15, 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): 46.59 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Stewart E-mail Address stewartae( aol.com
Telephone [phone] Cell# Fax# [phone]
7. Landowner(s)of Record (attach accompanied page to list additional owners):
ddenihan@
6030 Rock Service Station Road, LLC [phone] sworddevelopment.com
Name(s) Telephone Fax or E-mail address
950 Clifton Ave 950 Clifton Ave
Current Mailing Address Current Street Address
Clifton NJ 07013 Clifton NJ 07013
City State Zip City State Zip
8. Deed Book No. 016339 Page No. 00921 _ 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):
6030 Rock Service Station LLC
Name E-mail Address
950 Clifton Ave
Current Mailing Address Current Street Address
Clifton NJ 07013
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:
Donald Denihan [e-mail]
Name E-mail Address
104 Dartmouth Rd.Apt 630 104 Dartmouth Rd.Apt 630
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] 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
corre ed inf ation shout there be any change in the information provided herein.
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Sign ure Date
I, \c N.t�ca NI j \�\o. i c.- , a Notary Public of the County of�\ Q
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State of Ne a trra, hereby certify that` 1 )nl,pp\�e W\J 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 p day of\IC)\1;-- N'Q. , 20 -23
T NotaryIairrcU m , ak,c/� a,
Seal
My commission expires lO Dir, „QC./
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.�,-:a Expires October 26,2024
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