NCC243204_FRO Submitted_20241017

WAKE COUNTY FINANCIAL RESPONSIBILITY/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 cnnoiiN.n 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 Clifford Place Subdivision
2. Location of land-disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Clifford Road Latitude N35.658972 Longitude W-78.592637
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): 4.44
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Shujaat Ali E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
SASA Devleopment, LLC 919-455-0626 [e-mail]
Name(s) Telephone Fax or E-mail address
109 Raphael Drive 109 Raphael Drive
Current Mailing Address Current Street Address
Cary, NC 27511 Cary, NC 27511
City State Zip City State` Zip
8. Deed Book No. 018446 Page No. 00865 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):
SASA Development, LLC [e-mail]
Name E-mail Address
109 Raphael Drive 109 Raphael Drive
Current Mailing Address Current Street Address
Cary, NC 27511 Cary, NC 27511
City State Zip City State Zip
Telephone [phone] 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:
Shujaat Ali [e-mail]
Name of Registered Agent E-mail Address
109 Raphael Drive (same as mailing address)
Current Mailing Address Current Street Address
Cary, NC 27511
City State Zip City State Zip
Telephone [phone] 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.
Shujaat Ali Manager
Type or print Title or Authority
Sign a Date
I, N AT V ALL c ()PA S e'vn , a Notary Public of the County of W
State of North Carolina, hereby certify that S h U a- C e I appeared
personally before me this day and being duly sworn acknow dged that the above form was executed by him.
Witness my hand and notarial seal, this .Z 3 day of rf"'/' , 20 2-
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