NCC243038_FRO Submitted_20241001

E,} WAKE COUNTY FINANCIAL RESPONSIBIUTY/OWNERSHIP FORM
.-^ SEDIMENTATION POLLUTION CONTROL ACT
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 CAROLINA 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. Protect Name DOMINO'S ZEBULON
2. Location of land-disturbing activity: Jurisdiction WAKE/ZEBULON (Wake Co.or Municipality)
Highway/Street HENDRICKS DR. Latitude 35.8382 Longitude -78.3231
3. Approximate date land-disturbing activity will commence: 06/24
4. Type of development(residential,commercial,industrial,institutional,etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.0 AC
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity.
Name MACK PATTERSON E-mail Address MACK( PATTERSONPIZZA.COM
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
JTSJ INC 704-588-2611 MACKQPATTERSONPIZZA.COM
Name(s) Telephone Fax or E-mail address
9107-F SOUTH TRYON STREET 9107-F SOUTH TRYON STREET
Current Mailing Address Current Street Address
CHARLOTTE NC 28273 CHARLOTTE NC 28273
City State Zip City State Zip
B. Deed Book No. 019242 Page No. 00353 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):
JTSJ INC MACKAPATTERSONPIZZA.COM
Name E-mail Address
9107-F SOUTH TRYON STREET 9107-F SOUTH TRYON STREET
Current Mailing Address Current Street Address
CHARLOTTE NC 28273 CHARLOTTE NC 28273
City State Zip City State Zip
Telephone [phone] Fax Number
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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:
STEVE JANOWSKI SJANOWSKI©RNERSANDASSOCIATES.COM
Name E-mail Address
353 E SIX FORKS RD,STE 230 SAME
Current Mailing Address Current Street Address
RALEIGH,NC 27609 SAME
City State Zip City State Zip
Telephone 919594't626 Fax Number NONE
(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
JAMES,MCELROY&DIEHL,PA
Name of Registered Agent E-mail Address
525 N TRYON ST,ST 700 SAME
Current Mailing Address Current Street Address
CHARLOTTE,NC 28202 SAME
City State Zip City State Zip
Telephone [phone] Fax Number NONE
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.
MACK G PATTERSON II REGISTERED AGENT
Type or pri a7(9-r ---
Title or Authority
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Signature Date
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I, PikkA C Avn14¢ L-Lr ,a Notary 'Public of the County of ��- -1
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State of North Carolina, hereby certify that r e_ (2,y " nt )/\_ T 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 FN day of --iliSAP{3E19- ,20 A-
Notary
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