NCC243006_FRO Submitted_20240927

1131111111 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. Project Name 4)9 ��,C(tire/ /c.G -v'Je_
2. Location of land-disturbing activity: Jurisdiction /i. (Wake Co. or Municipality)
Highway/Street 11)A-g,rehitc0,5 La Latitude 3...5-.996 " ' Longitude -7g- 55/,'S-7/
3. Approximate date land-disturbing activity will commence: 9-30-2t V
4. Type of development (residential, commercial, industrial, institutional, etc.): I-Ge,iGQo„ 4-f
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0, 6 v
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name f-/4nk Na/vri 5 E-mail Address hmorrj f hJrY1 DO"is.Cc-1)-AI
Telephone 9/9-3yS",1's/Y Cell # 54 oie_ Fax# 4-'4
7. Landowner(s)of Record (attach accompanied page to list additional owners):
a_ - .4ue1v, L-Gc '119- 4,v9- '7/z4) ali,... ' imatle... gar,
Name(s) Telephone Fax or E-mail address
6-cD t.11s aF 040-5.-4 .. 121
Current Mailing Address Current Street Address
-
City State Zip City State Zip
8. Deed Book No. ZDJ Z. Page No./41/Z- /1Q/5/ 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):
h'.T reP/Y'i 5 C o�, I'nL 174-tarr,3 h,_f mr,tr, 15- C
Name E-mail Address
P d• a it e.t t $ s31 u �,,.,4Q .1 1..2:...a, S°',..-;,/c. >o/
Current Mailing Address Current Street Address
Rc -,1 0— lbL g71,2-'! 14 A__. ivL VI-/5-
City State Zip City State Zip
Telephone gm- 3y5>pS )if Fax Number ,q

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:
ame E-mail Address
A
Current Mailing Address6 F_Yc-----92,k2 0 A
Current Street Address
City State Zip City State Zip
Telephone W Fax Number 0,4—
(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:
,I h,i,\ —3. i h o,�y�s vn j-rha►,ti5orb.ev -/-A omps�kv.v„c. cep
Name of Registered Agent E-mail Address
i l 35— Qi 1( L nrvr Lte 5cci 2•045=' �
Current Mailing Address Current Street Address
(r.:,r i ►'U L a 25// ,Sc, e_ .
City State Zip City State Zip
Telephone oq - 2 y9- 5;3f/ Fax Number 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.
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Typ offprint na7fai Title or Authority
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Signature - '._ Date
I, r061-9 Elk' 1 f3 lb , a Notary Public of the County of I{)(, e_/
State of North Carolina, hereby certify that rL k ILS appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
1.42
Witness my hand and notarial seal, this c2`,,'�—day of J lPpwt ,(r , 20
MARY ELLEN POTANOVIC (\`% �o?�r.E��
Notary Public, North Carolina
W ke County Notary
My Con �sion Expires 5^, rn
June 16,2028 My commission expires l 20