NCC215305_FRO Submitted_20210927

=�W_ WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAYdCounty 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
NORTH CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
_ --- applicable, place NIA in the blank.)
Part A. �y/ leap k%.as KAJ8'B
A.WVS ' '
1. Project lame �b� � �� a Ott.NS RI cr z1"8a 16-o Atli C + �27 �
2. Location of land -disturbing activity: Jurisdiction - IJ4 KE (Wake Co. or Municipality)
Highway/Street pJ Latitude 5AM l' Longitude'>'
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): r i 6 C.0 1
5. Total acreaae_ disturbed or uncovered (including off -site utilities and borrow/waste
areas): _ a94 AcR-S
6. Person to contact should erosion and sediment control issues arise duringland-disturbingactivity:
Name SA td V Lk E-mail Address_ _ . , �! '"C_tku" C12 /WW'+
Telephone ' YOU- DLS Cell # ) - 71YO Fax # Al 1,A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
;jyr-��f��'rtp**moor
Name(s) ILC;sh)LLC.
I®"5-.Zl
Current Mailing Address
Telephone
CA-+R- A&M
Current Street Address
Fax or E-mail address
City U State Zip City State Zip
Deed Book No. Page No. 53 � S*q Provide a copy of the most current deed.
Part B.
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):
!Name E-mail Address
) ) C'+ A AMflZh ILIA
Current Mailing Address V
12AIg;A), C Z761,60
City V State Zip
Telephone t-r �� �{�Z ' /9P5J_
( .r)
Current Street Address _—
City
Fax Number
State
Zip

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
Telephone
State Zip
E-mail Address
Current Street Address
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:
AIM
Nam of Registered Agent
Current Mailing Address
E-mail 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.
A SA
Type or print nnam Title or Authority
13L"V
-�I iS ,; 4 u a J
Signature 0 Date
------------------------------------------------------------------------------------------------------------------------------------
I, Notary Public of the County of ^ -�,� �x t
State of North Carolina, hereby certify that —&zz appeared
personally before me this day and being duly sworn acknowledged that tW above form was executed by him.
Witness my hand and notarial seal, this day of _ VS 202
90
otary
Sea' * Y expires_
2
M commission ex ires
....f G-