NCC241604_FRO Submitted_20240607

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
WAKE
County 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 CAROLINA 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 7645 Falls Creek Lane
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street_Falls Creek Ln. Latitude_35.989151 Longitude=78.653656
3. Approximate date land-disturbing activity will commence: 5/20/24
4. Type of development (residential, commercial, industrial, institutional, etc.): single family
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_37,993 SF - 0.872 AC
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Travis Lam E-mail Address travis midtowncustomhomes.com
Telephone_919 410-5540 Cell# 919 410-5540 Fax# -
7. Landowner(s) of Record (attach accompanied page to list additional owners):
_Midtown Custom Homes, LLC 919 410-5540 [e-mail]_
Name(s) Telephone E-mail address
PO Box 31912 4509 Creedmore Rd. Suite 201
Current Mailing Address Current Street Address
_Raleigh, NC 27622 Raleigh, NC 27612
City State Zip City State Zip
8. Deed Book No._019470 Page No._00083
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):
Midtown Custom Homes LLC traviidtowncustomhomes.com
Name E-mail Address
PO Box 31912 4509 Creedmore Rd.. Suite 201 _
Current Mailing Address Current Street Address
_Raleigh, NC 27622 Raleigh, NC 27612
City State Zip City State Zip
Telephone [phone] 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:
Travis Lam [e-mail]
Name of Registered Agent E-mail Address
PO Box 31912 100 E Six Forks Rd suite 100
Current Mailing Address Current Street Address
Raleigh NC 27622 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] 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 formation should there be any change in the information provided herein.
//1, v,f '‘-;•;h 1
Type or print name Title or Authority
i re Date 7'9/J V
9
I, ENVY)(A L• S 2 1n,'V V , a Notary Public of the County of Vim/a 1Z
State of North Carolina, hereby certify that 1((1CV 13 L G w1 appeared
personally before me this day and being duly sworn acknowledged� that the above form was executed by him.
1 ► 1
Witness my hand and notarial seal, this I day of o9 , 20 2.y
ttaOAM
ry
Seal
My commission expires 3( 2- 7 / v �/
EMMA L SIEGMUND
I Notary Public-North Carolina I
Wake County
My Commission Expires Mar 23, 2028