NCC242620_FRO Submitted_20240827

IOW WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
may'" No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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
NORTH(Al:011NA 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 WF Lots 2372-2379
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Bright Lantern Way/
Highway/Street Mossy Falls Way Latitude 35.785 Longitude -78.426
3. Approximate date land-disturbing activity will commence: October 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): .786
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nolan Paussa E-mail Address [e-mail]
Telephone [phone] Cell# N/A Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
***Please see CCH RDU LLC 919-781-5225 [e-mail]
attached
addendum to Name(s) Telephone Fax or E-mail address
include
second owner 3739 National Drive Ste 128 3739 National Drive Ste 128
of lots Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
8. Deed Book No. 15478 Page No. 1623 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):
CCH RDU LLC [e-mail]
Name E-mail Address
3739 National Drive Ste 128 3739 National Drive Ste 128
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/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 Corporation, give name and street address of the Registered Agent:
Terry Carlton [e-mail]
Name of Registered Agent E-mail Address
3739 National Drive Ste 128 3739 National Drive Ste 128
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
Brittany Pinkham Accounting & Operatoins Specialist
Type or ri na e Title or Authority
Lo (1 - 24
Signature Date
I, Cp,.rr\ ��\C- « , a Notary Public of the County of
State of North Carolina, hereby certify that ' \ sc„v\-1 \w\\CArc:v"\ 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-A day of , 20
,okIE K/ ,, Notary
Seal �,P' 'ETA ��''�.
�L •;���'s My commission expires
Comm. Exp.
07-24 2024

Landowners of Record Addendum
Owner of lots 2375-2379:
Nash Wendell Falls, LLC 919-951-0719
Gabrielle Torre—[e-mail]
4020 Westchase Blvd., Suite 150, Raleigh, NC 27607
Deed Book No: 15478 Page No: 1623-1629