NCC240834_FRO Submitted_20240322

BPI. 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
717„.„,..,
County Unified Development Ordinance before this form and an acceptable erosion and
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. �fj / / /�G( "/�i/,/
1. Project Name �V 1 6C ,44 U lr-�.Jr!i x-vt.
2. Location of land-disturbing activity: Jurisdiction✓✓ l f,Ot (Wake Co.or Municipality)
Highway/Street✓� I01 �/14 tG'1tatitude 3 s (U Z Longitude /t fL
3. Approximate date land-disturbing activity will commence: 3 /v 102;
4. Type of development(residential, commercial, industrial, institutional. etc.): r`E-fji: /WA--
5. Total acrgage disturbed or uncovered (including off-site utilities and borrow/waste
areas):
6. Person to contact should/ erosion and sediment control issues arise during� land-disturbing activity: /� �,y�
Name 500 oAlWI�- l E-mail AddressSIOA et ffe'�7rl"/��� ��GU S,(C�I
Telephone W4S- 7w J Cell# !1`�_61J' 707 Fax# /1'/I
7. Landowner(s)of Record (attach accompanied page to list additional owners):
STEM G/ f 1-51e M Hg/i 0 ?M-6 11 c 5e01.50e'CO ,'4 0
Name(s) Telephone Fax or E-mail address
3 06 6 i'lx'atie bitVt ,DIZ MO6 MN, aliVe fit
Current Mailing Address Current Street Address
ItlVOaf SIG z 7wc Mom Nt Z 7cY
City IN
Zip City State Zip
t3. Deed Book No. I I"1`f.f Page No. O) 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):
Name E-mail Address
91li /Mls1N kJ / 5ik Z(1 '7/Z/ WO rivet 57E Za2
Current Mailing Address Current Street Address
Wel/ Nt Z76N 1111(.610.1 N Z76
City /� /(( State Zip
Zip CityState Zip
Telephone q/ r ^`J 5 '7 1 Fax Number Ni#

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:
/4 1606 B 1/U s S/1AIGg liogiej ' s 80/M ,m1
Name of Registered Agent E-mail Address
q/t'f VIA Wei M a 'f/i) P4YA u s1E 20
Current Mailing Address Current Street Address
IGI61/ N zl _S Mai/ AC z t
City a
Starte Zip City State Zip
Telephone lig- r - 7.7 O/ Fax Number 0
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.
slot D6/C(l/, - ova*
Type o i ame Title or Authority
z ,- 3-4F-YVI
Signature Date
f P4 . - 11 sr a Notary Public of the County of V" "`- '-
State of North Carolina, ereby certify that o`r1 r IV IV appeared
personally before me this day and being duly sworn acknowledg that the above 4m was executed by him.
Witness my hand and notarial seal,this� , day of 7A,�Lh ,20 o2-4'
1
,K ql,4,- i .'lki3Vil.l.STEPHANIE B. HARRINGTON `
NOTARY PUBLIC Notary I U
Seal.. COUNTY, N.C. My commission expires I t r ('" a'7