NCC204560_MODIFICATION Supporting Doc LOT 22_20210305 (3)

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
NOItI.[I CAROLINA 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 Lot 22 Avalaire Subdivision
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 5108 Avalaire Oaks Latitude 35.917 Longitude -78.626
3. Approximate date land -disturbing activity will commence: March 15, 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): single family residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.96 acre
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name McKenzie Olmsted E-mail Address [e-mail]
Telephone [phone] Cell # 919 280 9106 Fax #
FA
Landowner(s) of Record (attach accompanied page to list additional owners):
L & K Properties of NC 919 387 1455
Name(s) Telephone
2501 Reliance Avenue 2501 Reliance Avenue
Current Mailing Address
Apex NC
City State
8. Deed Book No. 016648
Part B.
Fax or E-mail address
Current Street Address
27539 Apex NC 27539
Zip City State Zip
Page No. 02395 Provide a copy of the most current deed.
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):
Loyd Builders, LLC [e-mail]
Name
2501 Reliance Avenue
Current Mailing Address
Apex NC
City State
Telephone [phone]
E-mail Address
2501 Reliance Avenue
Current Street Address
27539 Apex NC 27539
Zip City State Zip
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:
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.
Frank R. Loyd III
Type o rint name
Signature
Manager
Title or Authority
5
Date
I, fll ( 6n - I rf%1 i�1S' -exA a Notary Public of the County of la.4 (L�
State of North Carolina, hereby certify that __ li(�,Pga- 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 (+1_v _ 20 2'(
4
Notary
Seal
-_ 0 TA RY
My commission expires V.
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