NCC240643_FRO Submitted_20240305

"WI 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
NOiHI c:naui N. Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. (, ( r 1I L
1. Project Name�irPS � 1 \ SVklIVis1`�11 �0t 1 S I ! liLI , IS- (1 , I ( 0p" ('-I(p £ Z51- 74U
2. Location of land-disturbing activity: Jurisdiction fR DIPSV I lit (Wake Co. or Municipality)
Highway/Street 0,044 kTh(11(e LatitudeS, Longitude ^ 1C?, 442-
3. Approximate date land-disturbing activity will commence: 111\0 1(CL I Sfi 202 4 I-
4. Type of development(residential, commercial, industrial, institutional, etc.):ekecl(�evi'f lGl-I
5. Total acrea a disturbed or uncovered (including off-site utilities and borrow/waste
areas): CI
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: ��rr��
Name `�l Cf U1 S E-mail Address 41(Y1� iv `6.2)0( _t r-- n. Conn
r'
Telephone Cell #'(9' ` °1 1n
'-1 1(O3 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
40v-1-on
Name(s) Telephone Fax or E-mail address
Zd g fa I IS O-C Ko st d S4 20‘
Current Mailing Address Current Street Address
r\ L 7ILD1S
City n State Zip City State Zip
8. Deed Book No. DM5oS Page No. Z�j,sq 13C1rovide 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):
.�. \I Y1 NC- 1 .1f t Y�'1Q''11� SO 11/4A —Vry ku 1 S (�'
) l'l ( p vt,C
Name E-mail Address
2-07 `ca11 S' o Nk c-Cj S)-e..01dl
Current Mailing Address Current Street Address
1- l-u S
City State 'Zip City State Zip
Telephone R -1 1l, (o3 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:
C, I-. v `1O by
Name of R istere�i Agent E-mail Address
1 ® 04 . Cam, CA 20D
rrent Mailing Addresseit Current Street Address
Q��� Jt a'1(21S�
Jity nnStat''ett QZiip-� City State Zip
Telephone `c• ` 44- �1 ""' 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
cor ted information should there be any change iQn the information provided herein..,n
1(-Ct.Ci A \M,- a\i I.0 S.S4- (*%fy-bilC6-017 ka rApioN„
pe or print d e The or Authority
a&A-PIXA7 2— 22- 20 2 LI
Signature Date
I, 4 C6.41,ti-4-r , a Notary Public of the County of 64-)
��
State of North Carolina, hereby certify that i �r )- -c-XM: UtS appeared
personally before me this day and being duly sworn acknowl ged that the above form was executed by him.
Witness myhand and notarial seal, this 22 dayof -e-V 20 2 -(
� �_ J
S. ELAINE HUDSPETHs‘c-
NOTARY PUBLIC Notary
eMVAKE COUNTY, N.C. C(��,.Z--�
My commission expires