NCC241818_FRO Submitted_20240613

IWM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W• No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countyseientati Unifi be b
COUNTYsedimentation ed controlDevelopment plan haveOrdinance been completedefor and this approvedform byand Wake Countyaccepta le Departmenterosion ofand
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 Srnlrnlmcrlivi Estates
2. Location of land-disturbing activity: Jurisdiction Wake COCt.1t.; (Wake Co. or Municipality)
Highway/Street Old Si-moo-goad Latitude 35,53151D° Longitude "73• ' 114°
3. Approximate date land-disturbing activity will commence: \Mar& / Apr 2024
4. Type of development (residential, commercial, industrial, institutional, etc.) Z. =idevitial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 11. 5
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris SchiaVotle E-mail Address chriscc�r�etmstov�ehvlmesv�c,color
Telephone 611 g-355-C9546i Cell# Fax Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Old S+a15-Road, LLC chrisct7Sems+ovieholmesic.colm
Name(s) Telephone Fax or E-mail address
206212aleioh Street 206,-Ralei6)1h Street
Current Mailing Address Current Street Address
fmdrnay-Varivia, NC 2752 frngrnai-Varivia, NC 2752Xv
City State Zip City State Zip
8 Deed Book No 01 g043 Page No. D0051 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):
Old Stow-Road, LLC (Chris Schiavovie) chrisct�sewis+oviehovhesvic.com
Name E-mail Address
20Cv Rc+leic�h S+ree+ 206,-Paleis14 Street
Current Mailing Address Current Street Address
flAGMay-Varivia, NC 2352 ) F(AgMa4-Varivo, NC 23526,
City State Zip City State Zip
Telephone 611 g-355-6a54g 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:
Chris Schiavovie chrisZoteimstov1ehovnesvic,covv1
Name of Registered Agent E-mail Address
206)-Rale* Street 2DCv-Raleioh Street
Current Mailing Address Current Street Address
f14,04-Variva, NC 275262 ffri$ioj-Varivia, NC 2752Cv
City State Zip City State Zip
Telephone g1ci-355-Cv54cl Fax Number
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.
Chris Schiavovle Wlavia9ivig 1Mevvil9er
Type or pr. ame - Title or Authority
2/7-Z/2-44—
ignature Dat
I, ( kJJ tat \Lkrc' a Notary Public of the County of 1CA t 4
State of North Carolina, hereby certify that 1.\\•(V5 SC)' o-0 cn'-N-k. appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this V day of VI21or rd , 20 22'1
, M..B ,QO°
. '%'- Notary
Seal = :o�m+ssio„F+)' O i
▪ j My commission expires 1 � 2 V 20
N oTAR Y 0,: 7
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