NCC215334_FRO Submitted_20211018

RIP-M WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l 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
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 N/A in the blank.)
Part A.
1. Project Name Lot 35 Waterstone Manors
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Ballywater Lea Way Latitude 36.213830 Longitude -1 19.106780
3. Approximate date land -disturbing activity will commence: 10/4/2021
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 Doug Ross E-mail Address [e-mail]
Telephone [phone] Cell # 919-277-9921 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Monterey Bay Homes- Raleigh, LLC 919-277-9921 [e-mail]
Name(s) Telephone Fax or E-mail address
8801 Westgate Park Drive, Suite 106 8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh NC 27617 Raleigh NC 27617
City State Zip City
8. Deed Book No. 018482 Page No. 02197
Part B.
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):
Monterey Bay Homes- Raleigh, LLC [e-mail]
Name E-mail Address
8801 Westgate Park Drive, Suite 106 8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh NC 27617 Raleigh NC 27617
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 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 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
Telepho
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.
David Schenck
Managing Member of LLC
Type or pint name Title or A thority
A-4
Signa ure Dat
�7—T a Notary Public of the County of
State of North Carolina, hereby certify that bw i Cyl, 01C 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 ZTA day of 7SLI/V 20 z
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01-03.2026
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