NCC242175_FRO Submitted_20240718

IrWI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the 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
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
1. Project Name L(* `J i .-eAn I')V X (\R an (W'
2. Location of land-disturbing activity: Jurisdiction V3 eC.� W , (Wake Co. or Municipality)
A
Highway/StreetT\\< Pin Paq , itude 35.1 t C}3U°W Longitude— 1 U• ' 5c 3 07 `^ /
V v
ag
3. Approximate date land-disturbing aacctivity will commence: 3 uk.1 � ci, F r 1 i 2 02l
4. Type of development(residential, commercial, industrial, institutional,etc.): Y '-S I -fM J
5. Total acrr durbed or uncovered (including off-site utilities and borrow/waste
areas): a LPL, uottS
6. Person to`contact
t(should erosion� and sediment control issues arise during land-disturbing activity:
Name AA-2X 1J\J V Vino E-mail Address Cc� �V e \noun, cgma 1 .W'"
Telephone"1\v1' 2[)b- 561 UUp Cell# OU/M'e. Fax# M---A
7. Landowner(s)of Record(attach accompanied page to list additional owners): C . itii,c h
Ca&\-e,v-e iir m-e� 1 n C . No - 2 5- �1`�tp Gmot i 1-Cawl
Name(s) Telephone Fax or Ednail address
$LP» 61Slnoi0 IP►n-c LYl S.af\A-C
Current Mailing Address I Current Street Address
alc-e Fo(tgl- N C 21 Pa1
City State Zip City State Zip
22
8. Deed Book Nct 1`C1� . Page No. 01134-- Provide a copy of the most current deed.
Part B. 0 1 3o
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):
C -ere.. Ookt-cc 1 rlc can-VI-tv-e hom-e, era:, 1 , c 6 111
Name E-mail Address g
&QA-1 6-►S YIh-c Lin a MC
Current Mailing Add ess Current Street Address
Wfte bf ' N-c 251
City State o�, Zip City State Zip
(,�
Telephone "11"(�1 - 2, U"1 5— Fax Number 0)A

��. (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:
S � �p-� S�-eE ro Cc1`n i CIPChO - m c ay I
,e-� cam
Name of Regitered Agent E-mail Address
C&A-1 shoo ►Pl n-r Lr SC\YVT.
Current Mailing Address Current Street Address
.t\1c11c-e *EY-Ps- 1\1C. 2157
City (( �� State Zip City �/� State Zip
Telephone ( 3 �(1)14—((�^�,111 V Fax Number N1 r-J
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.
S - C-e( 0 SiC n 0 19Y-T J
T 1•e or print narhe Title or Authority
111TO CA D\20 \214
Signature Date
I, MeA , a Notary Public of the County of Wakhc.
State of North Carolina, hereby certify that S\-0..e., sice+arx v appeared
personally before me this day and being duly sworn acknowledg0 that the above form was executed by him.
Wdness my hand and notarial seal,this 20 day of aurva_. ,20 ?"--f
elissa A Hlavenka L L/L_ C(
Notary Public No ary
Wagkke County
SNbhh Carolina I
My Commission Ex•ires 7/28/2026 My commission expires G7J)ii k.�
`I