NCC241689_FRO Submitted_20240604

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
NORTH cnRoi.Inn 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 Gardner Farms Cluster Lots 9,14,22,23,32,& 42
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 508 James Austin Rd Latitude 35.5402155 Longitude-78.7204413
3. Approximate date land-disturbing activity will commence: 5/13/2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2,68
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rich Sherman E-mail Address [e-mail]
Telephone [phone] Cell# 919-422-2838 Fax#
7 Landowner(s)of Record (attach accompanied page to list additional owners):
New Home Inc., LLC 919-239-4747
Name(s) Telephone Fax or E-mail address
1611 Jones Franklin Road, Ste 101 Same as mailing
Current Mailing Address Current Street Address
Raleigh, NC 27606 Same as mailing
City State Zip City State Zip
8. Deed Book No. Page No. 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):
New Home Inc., LLC [e-mail]
Name E-mail Address
1611 Jones Franklin Road, Ste 101 Same as mailing
Current Mailing Address Current Street Address
Raleigh, NC C 27606 Same as mailing
City State Zip City State Zip
Telephone 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:
Richard L. Van Tassel, II [e-mail]
Name of Registered Agent E-mail Address
1611 Jones Franklin Road, Ste 101 Same as mailing
Current Mailing Address Current Street Address
Raleigh, NC 27606 Same as mailing
City State Zip City State Zip
Telephone [phone] Ext. 112 Fax Number N/A
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.
Richard Sherman Manager
Type or prat r,�arpe Title or Authority
/'L✓i 5/13/2024
Signature Date
4n6-rer r VJ , a Notary Public of the Cou ty of Y V .0
State of North Carolina, hereby certify that J kLAr P�MQn appeared
personally before me this day and being duly sworn acknowledged that the above forrn was executed by him.
Witness my hand and notarial seal, this 13 day of 420 ZL
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