NCC242486_FRO Submitted_20240819

COPP' WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WASNo 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
I applicable, place N/A in the blank.)
Part A. 1_
1. Project Name Cko_ e-4 £r''e.e ‹ L 0 f //
2. Location of land-disturbing activity: Jurisdiction LA/aL,Ke (Wake Co.or Municipality)
Highway/Street Ptilac,A C y!`«-V- Latitude 35.V$3 3 S'1 Longitude 78. 31i 9?/S
3. Approximate date land-disturbing activity will commence: ii I S-12v 2L
4. Type of development(residential,commercial,industrial, institutional,etc.): Rs-de-r
ficti
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): , 5..5'
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:o
Name 1¶ek ttcA pt E-mail Address 0 et.kGivlf/.00in4G 16‘41 hovheS ci)9 vh.- 'I ' cot"
Telephone Cell# ci lq-- )S-6 d'f D Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
Sc.** Few wvm S8S-3aI-ISgg
Name(s) Telephone Fax or E-mail address
3 9/(a Wl wo!i o. Poi,u4 Rd .
Current Mailing Address Current Street Address
RaAeilk NC a961 o
City State Zip City State Zip
8. Deed Book No. I ci S 9/ Page No. o?13 l 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 off�all responsible parties on an attached sheet. Include requested information):
I�Pibucc, i`inn'to Q l etAi-alf ocxX lS-vigzcusAp1/4, Kovhes 60 .QY1�a i`i Eo tn,
Name E-mail Address U
kob1l 6J` L .
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone19119'c1 c/ 4, e ) 0 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
RGCct ft4pI�vL / 0. �is� ►�e_t�6e_Iri
Type o int name Title or Authority `J
7/ ,82,4 0 Q LI
Sig ure Date
I, 5 ,440,Pel J. le-r:Cr� ,a Notary ublic of the County of �'+�/�`
State of North Carolina, hereby certify that /lebe e ,/! J ne/( appeared
personally before me this day and being duly sworn acknowledged that tabove f rm was executed by him.
Witness my hand and notarial seal,this Uhl day of ( .)J ,2/ ,20 G (-(
`'x,0111li aunrurn. ' ^ "'�_
C)W ;`i9 Notary
Seal < J -TA ' , .
�./. . �� "=.�`�'_ My commission expires 01 to (Z02
acre
E.to _ My Comm. Exp. o
01-•03-2026 -
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