HomeMy WebLinkAboutNCC215397_FRO Submitted_20211007WAKE 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
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
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 fit,%L 2Lcnc7 K /,Or / p
2. Location of land -disturbing activity: Jurisdiction idA-Ktr WunJ-fr (Wake Co. or Municipality)
Highway/StreeQ!s(5 5fWyAI'6kr Cr Latitude 3'• 977 Longitude.
3. Approximate date land -disturbing activity will commence: 8-Z3�Zo
4. Type of development (residential, commercial, industrial, institutional, etc.): ►2�Sii)
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): C> , Ll 2
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address 61 le-}C �- f ac S�r��b,►� , Ca.,-
Telepho
Cell# I1q-1I1-0-9yy1 Fax it
7. Landowner(s) of Record (attach accompanied page to list additional owners):
L�C,�cY' Cu STo� �lrr1 �
Name(s)
550Ll
Current Mailing Address
9tg -7g! -38',&,e
Telephone
Current Street Address
Fax or E-mail address
OALo6 u N
City State Zip City State Zip
8. Deed Book No. Z-C> 21 Page No. 139 -'?`/O 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):
4a ACY LuS7an x0►NeF5 etar`
Name E-mail Address
53bq 51X xs &'-) X-rcrl"00
Current Mailing Address
f2k � N , AIL 2700
City State Zip
Telephone 90 --79/ — 3 8V
Current Street Address
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.
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Type or print name
Si ature
O Iry art_
Title or Authority
W-Kb- Goat
Date
I, Ly n r1 e A L(xj n e , a Notary Public of the County of % QA e-
State of North Carolina, hereby certify that U ct n i e 1 W . R os S e 11 appeared
personally before me this day and being duly swum acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 1(�day of A u Q u $ A' , 20-2S_
1 P' �yN �U•,nn,t. G �Cwt
01 Notary 7
Seal
My commission expires W� 31, av,;tkc
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