NCC215788_FRO Submitted_20211019

WADE COUNTY FINANCIAL RE PONSIB1LJTY OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may in any la 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
\i1K L314: k M I Environmental Services, Water Quality Divlsiorr, (Please type or pant and, if the question is not
applicable, place NIA in the blank,)
Part A.
T6
Project Marne2. '--
Location of land -disturbing activity: Jurisdiction _ 4<f- t o , (Wake CO3 or Municipality)
laud �
Highway/Street Pe $; rye- � w Latitude Longitud _ 73 ? 9 O
3. Approximate date land -disturbing activity wilt oommence: _ 10 - { - I
4. Type of development (residential, commercial, industrial, 'rnslitutional, etc.): a eAejl
5, Total acreage disturbed or uncovered (including off site utilltles and bof rowAvaste
areas):— r -
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mad Address
Telephoned R-LIKO _ eil # '7 Fax
Landowners) of Record (attach accompanied page to list additional owners):
Names) Telephone Fax or E-mail address r#•••
Qurreat Mailing Add ess Current Street Address
Y � -� F J ?1�
City Mate Zip City State Zip
Deed Book No. c)- Page No. C)1&15 1_ Provide a copy of the most current deed,
Part B.
Person(s) or firms) who are financially responsible for the land-disturbMg activity (Provide
comprehensive list of all responsible parties on an attached sheet_ Include fecluested information):
t _* sr . �s n e-l{,VILL Y''i
Name 1E-mail Address
Current Mailing Addi4ss Current Street Address
City State Zip City State Zip
Telephone ' .' /� Fax Number

, (a) If the Financially Responsibte Party is riot 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 ari y
matter relafing to the Wane County Erosion and Sedimentation Control Ordinance andlar Land
Disturbance Permit: 1r
r - ;Q -, � V � `I j�' fir, 0 M 011
C �+
Name E-mail Address ^,
..
Current Malling Add ress Ouirent StreeAddress
_ C s&�+
City State Zip city State Zip
Telephone �'x `!ate - o ')"l 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 Assurned Marne. If the Financially responsible
Party is a Corporation, give name anti street address of the Registered Agent
kii
Narne of Registered Agent E-mail Address
Current Mailing A dress
t;w
City Slate Zip
Telephone q lef - (P • 0V)
Current Stfeet Address
City
Fax Number
State Zip
The above information is true and! correct to the hest 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 attomay- i n-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 ' forrr7ation should t
r be any change in the information provided herein.
Type p print Title or Authority
ignatu Date
1, a Notary Public of the Counter of�.
State of North Carolina, hereby certify that 'AY J appeared
personally before me this day and being duly sworn ackrimi ged that the above form was executed by hirn.
Witness my hand and notarial seal, this clay &AAc4 i >o vim,
E.
Ndtary
' OTARk,My commission expiresPOBLIr-
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