NCC241052_FRO Submitted_20240408

ESPONSIBILITYIOWN ACT IP FORM
1121.. WAKE COUNTY FINANCIAL R CONTROL the W ake
- - SEDIMENTATION POLLUTION or more acres as covered erosion and
activity on one acceptable
land-disturbing and an Depart. ment of
No person may initiate any Ordinance before this form Wake County
ment roved by if the queson is not
WAKE County Unified Development
have been completed and approved
or print and,WL Water Quality Division. (Please type sedimentation control p
COUNTY Environments► Services,
N<„z " ""°"N` applicable,place NIA in the blank.)
Part A. ��t/` `�� 7�
1. Project Name W �,v-C.. (Wake Co. or Municipality)
2. Location of land-disturbing activity: Jurisdiction
Longitude
Latitude
Highway/Street
vest -�/' Ic:�l
3. Approximate date land-disturbing activity will commence:
Type of development kresidenti. ommercial, industrial, institutional, etc.): borrow/waste
4. (including off site utilities and
disturbed or uncovered
5, Total acreageactivity:
areas): land-disturbing
S%el v Y y-b� ICV'
6
Person to contact should erosion and sediment control issues aris during
,�n,,V, S�efj�, E-mail Address. �
Name/v _ /�/f/� Fax# /V
f I g l - 5 --e 39 Cell#
Telephone( 1
7. Landowner(s)
of Record (attach accompanied page to list additional owners):
/f`
L v, I dt o S -TnG- Cci wf J -S --033 Fax or E-mail address
Telephone
Naa e(s)) C 0 11lPW �in/G�eY t t� p lace St.�,{� 1 ' C>
�qo Nam-' sv°
O Current Street Address a�L/0
Current Mailing Address G N� �J
:�G 9-7State Zip
City State Zip City y
City of the most current deed.
U�q q�.�J3 Page No.d �� Provide a copy
8. Deed Book No.
Part B. activity (Provide a
Persons) or firms(s)f who are financially responsible for the land-disturbing
1 - s IG�VS,�
sive list of all responsible parties on an attached sheet. Include requested iinnf^ormation :
compiii •�. MSirtLlr n U vi i,( t1
V i W`' S Na e E-mail Address
urge �
/,� a /vew v�la-V evt lace, 5
5N0 !Ve-u' G eV 1,
' Current Street Address _ (�
i / �7���J
Current Mailing Address n75�G � fc
(e r� Zi rl City State Zip
State p t
City i V
_ Fax Number
Telephone.

a designated agent in
identify out of any
is not a resident of Wake County, roceeding arising
oy notice,Party leading in any action or legal p
2. (a) If the Financially Resp process, p
Wake County to receive anyt Erosion and Sedimentation Control Ordinance andlor Land
matter ce\atImg ko the Wake Coun y
Disturbance Permit:
E-mail Address
Name
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:
web 11 wcA-vv`c I I c 1 v,,1/4�� I d eM.
coltri
Name of Registered Agent E-mail Address l/
549 ive,“v Wc&-v e-v 1 y pl_s v i le 6 ,0 iVC.A-v Wa-V Y t y r 'e scy4+e, Igo
Current Mailing Address /lgoi Current Street Address
cry A/c a7511 ca-V y Ate- SL-7579
City (� State Zip City State Zip
Telephoneellq) 8 58 g 3e 3 Fax Number ,Wk
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.
1j . Imp G EA. -I C124)Lc, 1 <
Type or print name Title or Authority
1"-- / A---- n(1, RIZzi
Signature Date
I, . ./A-NOle A .,S. j)t J AJt=1 , a Notary Public of the County of IAIe
State of North Carolina, hereby certify that Si 1.4 ES l.E 1 C `Cf OL-L appeared
personally before me this day and being dulyl7 sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this (C-, day of J 0_ , 20 23
-- W1DRA J. LINNEY otary
NOTARY PUBLIC My corn ' sion expires �/Z-/Z-�
WAKE COUNTY, N.C.
My Commission Expires 3/23/2027