NCC201819_FRO Form Submitted_20200505

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
NORT" CA 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 Alta Morrisville
2. Location of land -disturbing activity: Jurisdiction Town of Morrisville (Wake Co. or Municipality)
Highway/Street Morrisville Carpenter Rd. Latitude 35°49'01.5"N Longitude 78050'59.32"W
3. Approximate date land -disturbing activity will commence: May 2020
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 11.3
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ben Johnson
E-mail Address [e-mail]
Telephone Cell
# [phone] Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
WP Fund V Morrisville, LP
[phone] [phone]
Name(s)
Telephone Fax or E-mail address
1414 Raleigh Road, Suite 429
1414 Raleigh Road, Suite 429
Current Mailing Address
Current Street Address
Chapel Hill NC 27517
Chapel Hill NC 27517
City State Zip
City State Zip
8. Deed Book No. 017801 Page No.
02412 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):
WP Fund V Morrisville, LP
[e-mail]
Name
E-mail Address
1414 Raleigh Road, Suite 429
1414 Raleigh Road, Suite 429
Current Mailing Address
Current Street Address
Chapel Hill NC 27517
Chapel Hill NC 27517
City State Zip
City State Zip
Telephone [phone]
Fax Number [phone]

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:
Jamie Schwedler [e-mail]
Name E-mail Address
301 Fayetteville St., Suite 1400 301 Fayetteville St., Suite 1400
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Caitlin Shelby Authorized Representative, WP Fund V Morrisville, LP
Type or print name
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Signature
Title or Authority
11.19�20
Date
I, Dir(� f�IltS-, �y a Notary Public of the County of 01-1115
State of North Carolina, hereby certify that C`►,%1 i'l 1, f�e/(2 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, thisL (4 day of 20
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