HomeMy WebLinkAboutNCC215154_FRO Submitted_20210914WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM 1 t'
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
sedimentation control plan have been completed and approved by Wake County Department of
COUNTY ` Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name
2. Location of land -disturbing activity: Jurisdiction vV 4 k e Co, (Wake Co. or Municipality)
Sot I -DiScove,r d"',.a8Highway/Street Tr .i j I____titude 35 • i` `�O Longitude �O
3. Approximate date land -disturbing activity will commence: Itit Iz t }} 11
4. Type of development (residential, commercial, industrial, institutional, etc.):
$024 _1"SC0y0-4 FAl Isl'r&d Crud moo r MOnor Lo�Z
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): r Cp-t
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name A l n W iS E-mail Address A C n Ql P-S bA r+o n i n C. Co M
Telephone 1 91' 06 51 5 S Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
►fit`+Es C3 ''-' r �r-s -1tq-41J5- s-755
Name(s) Telephone Fax or E-mail address
Z 0 1� cm v Cam" C"
Current Mailing Address
j2✓,'t,C't fi 4 r'L-
City State
8. Deed Book No. [8z
Part B.
Current Street Address
Zip City
Page No. Z'4-11
State
Zip
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):
� 5 /4 t•'� .a.3 lam n�( � .v < . A ,.� (1) 14.44 CS PT
Name E-mail Address
7 D B CeW C—d T" G-, ,
Current Mailing Address Current Street Address
[z' -t„l a L+- ,vcr 27&01 `'
City
Telephone.
State Zip
�4S- S775
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
Current Mailing Address
City
Telep
E-mail Address
Current Street Address
State Zip City State Zip
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 State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
w r LA-t .4�-. �- .t �.� w F.4_(1
Type or print name
7_t��
Signature
-------------------------
I, Jul Y1 t E"r
-L��
IS@-�'
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that V r I ft &rn hj !Gn wej IS 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 1 P'day of k US+ 20 2
7 �_ 11 . I,
lEI�INIFER R. KISER Notary
Notar$&gplic, North Carolina
Wake County
My Commission Expires My commission expires_
Apfil03, 2022 y