NCC233154_FRO Submitted_20231024

1111.1111 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentatiCountyon 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
•
1. Project Name 1"1 l"1 C om r uell Cu-7(CA5
2. Location of land-disturbing activity: Jurisdiction pJACC- (Wake Co. or Municipality)
Highway/Street Sv C. i I ntv_ V(�'VLLatitude 35.'7.2,5yyy Longitude —78. 6573 56
3. Approximate date land-disturbing activity will commence: 10 /2023
4. Type of development (residential, commercial, industrial, institutional, etc.): OfficeluJokkcA.6e,
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3, a.C•
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1113.?V o don2jp. 2_ E-mail Address gG e R6 Cot 1.NC I
Telephone(5 413) 250- "lac Cell # Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
iJ ?meet'4fe._ LLC ( eL13) . oc
Name(s) Tephe Fax or E-mail address
2021 rc-i'- 3 q 65 3 vvtc rr ?ivd
Current Mailing Address Current Street Address
30-(c19k NL 214 L. 27603
City State Zip City State Zip
8. Deed Book No. IN 7569 1 Page No. °coYsj 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):
J.o' 14-- (;oh 7.6.le R G @ R.E CbMNt•
Name E-mail Address
-?89 S. �e1•na 1•2
Current Mailing Address Current Street Address
U-Netrde I( kL 0-7 51I
City State Zip City State Zip
Telephone NI-1 2SC /2 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:
j AMoAJ Coin LEZ RE" t R.6Cow-VE
er—
Name E-mail A ress
7 c Se 1,— -
Current Mailing Address Current Street Address
WeA8G I 1UC- 27591
City State Zip City State Zip
Telephone j�3 - 250 giv..6 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:
1 P copes z 7 R G@_ P /.to &T
Name of Registered Agent E-mail Ad ress
S. SC-1MC4.
Current Mailing Address Current Street Address
(, )crtde!( A.1 C. t27b91
City 2 State Zip City State Zip
u
Telephone /3 250 41l2G 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.
a skin CortZa e7 Prc S t deed—
Type
or print name Title or Authority
A , ,. �o /2®23
Signatu -' t/ Date
, a Notary Public of the County of 141 L$ph
State of North Carolina, hereby certify that'rn,� 6iftpnZo- 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 /0 day of Q , 20073
KAREN MOORE LAMM
NOTARY PUBLIC
Wilson County
North Carolina otary
Seal My Commission Expires March 15,2027
My commission expires P11�4,rc.Y� �5+ 2 '7