NCC215129_FRO Submitted_20210913

MW_
WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
0 ��_ SEDIMENTATION POLLUTION CONTROL ACT
WAW/�T No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
I 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
I Project Name
2. Location of land -disturbing activity: Jurisdiction _ Wake County (Wake Co. or Municipality)
Highway/Street N. Arendell Ave Latitude 35.8415 Longitude-78.32606
3. Approximate date land -disturbing activity will commence: May 1, 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and areas); borrow/waste
1.32
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address [e-mail]
Telephone [phone] Cell # 919-365-0381 Fax # nla
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Stephen Jordan Properties LLC
Name(s) Telephone
Fax or E-mail address
20 Bunn Avenue
Current Mailing Address Current Street Address
Zebulon NC 27597
City State Zip City State
Zip
8. Deed Book No. 013544 Page No. 01490-01492 Provide a co
py of the most current deed.
Part B.
Person(s) or firm(s) who are financialiy responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Charles E. Bright IV ,' I Name �-
U E-mail Address G a r(\
800 * a'/l 1✓m �00 S
C rent Mailing Address Current Street Address
NC -2754a7.
City State Zip City
State Zip
Telephone [phone]
Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated ag
Wake County to receive any notice, process, pleading in any action or legal proceeding arising oumentation Control Ordinance and/or nt in
t eany
matter relating to the Wake County Erosion and Sedimentation Land
Disturbance Permit:
r ,1
Name h J�1 �, 9 a &0
E-mail Address
V�
urrent Mailing Address
rr Current Street Address
17 6
City State Zip City
State Zip
Telephone ss — a:t 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone
Fax Number
State
Zip
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.
iQ I
r
Type or print name
oignature
Title or Authority '
Date
v� j 1 ` I� ►Cholt a Notary Public of the County of
State of North Carolina, hereby certify that thu g f `•
personally before me this day and being duly sworn acknowlledged that the ab ve form was executed by him.appeared
Witness my hand and notarial seal, this day of MQ M�)
120-�-_
Ir O TAR ytiO(N Notary My commission expires /01'0
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