NCC243278_FRO Submitted_20241025

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WADE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
D before
COUNTY sedimentationCountyUnified control planevelopment haveOrdinance been completed andthis approved
form byand Wake Countyacceptable Departmenterosion ofand
NOR IH(AIM!.INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. /�l
1. Project Name C7«/7dQh/4,115
2. Location of land-disturbing activity: Jurisdiction�c,Itz. (;(44J7 (Wake Co. or Municipality)
Highway/Street(1f/,/L CicS-74-P/It, Latitude 36),0;g/lc0 Longitude '725+, .Sq/(d-/2
3. Approximate date land-disturbing activity will commence: I /vO) 2O2-'I
4. Type of development(residential, commercial, industrial, institutional, etc.): QGSideal/, /
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0, 130
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name &-) 4(eIID E-mail Address bxretioe PX,e he,+iu, ,c.0 _
Telephone e//°- 3/7—0 79-/ Cell# em-1/ -6,?'//Fax# N,i�
7. Landowner(s)of Record (attach accompanied page to list additional owners):
4,'ld, G.,,,, y G7G 0I1 B/G-co: / s t.r»G eXc-1r ; i�� .Co,t.�.
Name(s) ,/ V / Telephone Fax or E-mail address
`651 tdNde c/d jr;i 5 �O �2) FGM iv - S .-i k- -8
Current Mai ng Address Current Street Address
City / State Zip City / State Zip
8. Deed Book No. /' 4/Z Page No. 2.2_e I 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�i))a/
list of all responsible parties on an attached sheet. Include requested information):
/ / L<AG I) C-orl,A- )y UC �tiInel00(04-C builotirJ
l.�, ‘ Gors---
Name / E-mail Address
100
Current Mai �^
g Address Current Street ddress
(vtlei l-,, ifJG 27-6g' A/6; h /VC 27G o1
City / State Zip City State Zip
Telephone 1 11-gIO-6 32 1 Fax Number 1U/4-

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:
IA-
Name E-mail A AAdress
Current Mail g Address Current Stfeet Address
Cit f %ate Zip Cityt A/tf State Zip
Telephone (/7A Fax Number (7/1
(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:
A (ems (-lock a sA-6 c+� 1 IAi n j co
Name of Registered Agent E-mil Address
c)oO 4; f'c (A D-4,6 5 ; 9) °)Od R 4 ;'&iel J)6,Ae, ,;-14, so
Current Mailidolg Address Current Street Address
City / State Zip City I State Zip
Telephone */?"" �/j S'" / b 9 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.
4f 7 �- / 7 ei/1✓l�i7�l� Cabe/
Type p nt name Title or AutworitV
c9._
Signature Date
I, Taiy Ct 4 , a Notary Public of the County of 7(State of North Carolina, hereby certify that x \to 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 IS day of 0 , 20 2,4
�G, �Ssion .� �,' Notary a-A- a? _
Seal ;U� NpTARY N ? My commission expires OW
�s, PUBLIC
.'?,29 tom. `