NCC241748_FRO Submitted_20240612

. owWAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
A No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
ia-
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
ni�RTli CAROItNA 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 £1/1' 67? &'rrnoll liiilrlgy.,) 6s1-i-hs
2. Location of land-disturbing activity: Jurisdiction Wit te Co • (Wake Co. or Municipality)
Highway/Street 1-p41404 P/i o'at Latitude 44.. Off-? Longitude —7?'• 6-17 9
C av1- -
3. Approximate date land-disturbing activity will commence: ,/ h' 9 I / , - 34
4. Type of development(residential, commercial, industrial, institutional, etc.): Res, d rr Ad /
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): d 6, ccv S P
6. Person to contact should erosionactivity:and sediment control issues arise during land-disturbing
Name '•'''G K.+01 ao E-mail Address eri.c.&it-oi KOIir.c1, 6V%Lt e-Pifil
Telephone gio •o`er/•00107 Cell# f/f /.49fv7 Fax# f✓/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
OK pesitn 8010' 9'l9.,q/.09o7 en`cocelk/,s;',,b+•d,,l.c
Name(s) Telephone Fax or E-mail address
I S mT Deli C2L 3 11 /721- EDEri P�
Current Mailing Address Current Street Address
Caryl tic 0-75-I 8' Gc►r)l Alt 9-7s 18
City v ,`State Zip City State Zip
/�'T 8. Deed Book No. I -/ 6 V
14 Page No. 0 79 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):
f94 aeJ ►yr Fviid er*C — A At;yydeie,l64(®/l
Name E-mail Address
31 V yn r. c//n' Pi - • 1 l 1 f n7- de Ate-
Current Mailing Address Current Street Address
earia WC- r75-17 r Givry Nil 75'7 Y
City /� State Zip City State Zip
Telephone i q aq/ -49617 Fax Number iL/f

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
E v r Dntol11 ejhjer@telkdtr►(Irby►1).eoe•
Name E-mail Address
1 g jn#• allot flue-- 31? Yn r Elm A —
Current Mailing Address Current Street Address
earl 1 loci eorb--- a VV7S)
City State Zip City A State Zip
Telephone q,q• '1 -3ta'0 Fax Number 41 A
(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 Corporatlot!,give name and street address of the Registered Agent:
iV/i' 26)) a Opl- - eltp9 'b 44 Ries i bu')o.r��
Name of Registered Agent E-mail Address
i ri. ,ltt✓ P)Ace- �18 ,4 " bL i21 i8-
Current Mailing Address - .. Street Address
City State Zip City State ZIP
Telephone g i g-tiap' 3 Pip Fax Number Kg !c
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.
&lc 11 ,7 X.,.1-G vA
Type or pri Title or Authority
14 Z//) )1.// eit5ei 97?-+
Signature D
I, 7—uJ 4/.7 2 cJ k ,a Notary Pubic of the County of wR kc
k ;c(d appeared
State of North Carolina, hereby certify that .,if Gthat above loan was by him.
personally before me this day and being duly sworn acknowledged
Witness my hand and notarial seal,this a 4f d day of M ►Z0
JASON LUK "IL
NOTARY PUBLIC Nary
Wake County, North Carolina
My Commission Expires 09/21/24 My won expires 0 (Vol.V'l