NCC243510_FRO Submitted_20241113

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W� No 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
NORTH CAROL 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.
1. Project Name Creech Road Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake CO. , Garner (Wake Co. or Municipality)
Highway/Street_405 Gatewood Dr. Latitude 35.7320 Longitude.=78.6003
3. Approximate date land-disturbing activity will commence:_ 05/06/2024
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):32acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Patrick Busse_ E-mail Address patrick.busset7a.habitatwake.orq_
Telephone _ Cell#_919-793-6633 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
HABITAT FOR HUMANITY OF WAKE COUNTY INC 919-833-1999 [e-mail]
Name(s) Telephone Fax or E-mail address
2420 N. Raleigh Blvd. 2420 N. Raleigh Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27604 Raleigh NC 27604
City State Zip City State Zip
8. Deed Book No. 017471 Page No. 02302 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):
Habitat for Humanity of Wake County _ patricia.burch2habitatwake.org _
Name E-mail Address
2420 N. Raleigh Blvd. _ 2420 N. Raleigh Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27604 _ Raleigh NC 27604
City State Zip City State Zip
Telephone_919-833-1999 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:
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: t
act, t'.ftcki (F1u -74 it ktfi t 1�ii �i,h. f# C%`1 b +,C`°
Name of Registered Agent E-mail Address
•
0-420 V A i€c h 411-1- 2L1 ,) Kt. ketiei k
Current Mailing Ad ss Current Street Address
'QC z-Rtiati
City J State Zip City _J State Zip
Telephone GI ict g 3 3 i el 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.
-Pak ill CZO- CAT'
Type or print name Title or Authority
CO-6PGL., P ft (4•3© . 20
Signature Date
I, 1 ? f 'l4 , a Notary Public of the County of J J -
State of North Carolina, hereby certify that t r)C Bt.t r ') 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 day of / I r L , 20 _
DAIBA çTOzAY - _ _
Notary
Seal NTY PUBLIC
SNAKE COU , N.C. My commission expires