NCC240788_FRO Submitted_20240319

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing un' v�yon one or more acres ao covered by the VVaka
WAIdCounty Unified Development Ordinance before this form and an acceptable erosion and
K���ll��-F�� sedimentation control plan have been completed and approved by Wake County Department of
NORT--x—'^' '/w^ Environmental Services, Water Quality Division. (Please type ur print and, if the question innot
applicable, place N/A in the blank.)
Part A.
1. Project Name Lot 15 Wexford Reserve
2. Location of land-disturbing activity: Jurisdiction Wake County (VVoko Co. or Municipality)
Highvvay/StreetWe«ford Woods Lane Latitude 35'998340 Longitude -78.547630
3. Approximate date land-disturbing activity will commence: 1/14/2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.56
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Keith Richardson Name E-mail Address l'acksoO@a[ho[0eS.c0[D
Telephone [phone] Co||# 919-602-3905 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
MODtereyBay - Raleigh" L[C 919-277-9921
Name(s) Telephone Fax or E-mail address
8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh 0C 27617
City State Zip City State Zip
8. Deed Book No. 019443 Page No. 00337 Provide a copy of the most current deed.
Par1B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing ao(|v|h/ (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
MB Rale\gh [LC UaOks0n@a[ho[Des.coRl
Name E-mail Address
8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh NC 27617
City State Zip City State Zip
Telephone [phone]g21 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:
David W. Schenck
Name of Registered Agent E-mail Address
8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh NC 27617
City State Zip City State Zip
Telephone [phone] 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.
David W. Schenck Owner
Type r int name Title or Authority
a711( 614 „Th
-73
ignature Date
�a
I � O C� - (; ( (J'�O\J , a Notary Public of the County of
State of North Carolina, hereby certify that Oavd w V 1° -L- 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 [ -1 day of oe(CR, °DOE , 20 r2
C / /%t
Notary
Seal /t ,
s — — — .� _ �. _ My commission expires i (l► I rv"`S
VERONICA CORDOBA
4 Notary Public-North Carolina
Wake County
4 My Commission Expires Jun 25, 2028