HomeMy WebLinkAboutNCC215320_FRO Submitted_20210928WAKE 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
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
NOR II (AIUIIJNA 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 Bella Terra Lot 6
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Winding View Latitude 35.921537 Longitude -78.676744
3. Approximate date land -disturbing activity will commence: 08/23/2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.60
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Andrews E-mail Address eandrews@exeterbuilding.com
Telephone 919-538-7295 Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Exeter Building Company LLC 919-455-1664
Name(s) Telephone Fax or E-mail address
900 Ridgefield Drive Suite 50 900 Ridgefield Drive Suite 50
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
8. Deed Book No. 18420 Page No. 2780 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):
Exeter Building Company LLC ayost@exeterbuilding.com
Name E-mail Address
900 Ridgefield Drive Suite 50 900 Ridgefield Drive Suite 50
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone 919-455-1664 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
Telephone.
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Telephone
State
E-mail Address
Current Street Address
Zip 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.
Alex Yost
Type or pr me
i at re
Managing Member
Title or Auth ity
Date
a Notary Public of the County of
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State of North Carolina, hereby certify that ,419)60kt�w 00- appeared
personally before me this day and being duly sworn acknowledged t at the above form was executed by him.
Witness my hand and notarial seal, this <
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