NCC241941_FRO Submitted_20240625

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
V r No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAIN:, 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
�,,,,,,, .41U1,11�4 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 Chapel Creek Lot 14
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Peaceful Creek Tr._Latitude_35.8828587_Longitude_-78.3494228
3. Approximate date land-disturbing activity will commence: 5/1/2024
4. Type of development(residential,commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .971
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Scott [e-mail]
E-mail Address
Telephone Cell# 919.524.6558 Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
On Point Construction LLC 919.524.6558 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 3 Wendell NC 27591 120 Lu Tom Ln.
Current Mailing Address Current Street Address
Wendell. NC 27591 Wendell, NC 27591
City State Zip City State Zip
8. Deed Book No. 019556 Page No005374)0538 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):
On Point Construction LLC [e-mail]
Name E-mail Address
PO Box 3 120 Lu Tom Ln.
Current Mailing Address Current Street Address
Wendell, NC 27591 Wendell, NC 27591
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 Pennrb
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:
Joseph Scott IGng scott©onpointnc.com
Name of Registered Agent E-mail Address
120 Lu Tom Ln. /20 LU -70
Current Mailing Address Current Street Address
Wendell, NC 27591 (,JeN 'l AC Z 7Sq t
City State Zip City State Zip
919.524.6558 N/
Telephone 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.
Scott King Member
Type or print name Title or Authority
Signature ( Date
t
I. KO_ 8Gytar- ,a Notary Public of the County of L✓ kt-
State of North Carolina, hereby certify that Sa St P ti r` "?- appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
WitnessLi
my hand and notarial seal,this 1 day y of ,20 1"
�a��••�' noo�e,,,, Notary /
tea
1� 1118n�, �'.��"s My commission expires ��/f/)-C�"4(
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