NCC215879_FRO Submitted_20211022

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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 C;AROLINA 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 Knightdale Station
2. Location of land -disturbing activity: Jurisdiction Knightdale (Wake Co. or Municipality)
NWC Carolinian Ave. &
Highway/StreetMorning Flyer Way Latitude 3 5- 4 7- 5 5 N Longitude - 7 8- 2 7- 3 7 W
3. Approximate date land -disturbing activity will commence: September 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): 16.90 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Peter Bellantoni E-mail Address pbellantoni@tollbrothers . com
Telephone
Cell# 919-609-6111 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Toll Southeast LP Company, Inc. 919-321-4800 [e-mail]
Name(s)
1140 Virginia Drive
Current Mailing Address
Telephone
1140 Virginia Drive
Current Street Address
Fax or E-mail address
Fort Washington, PA 19034 Fort Washington, PA 19034
City State Zip City State Zip
8. Deed Book No. 018627 Page No. 00045 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):
Toll Southeast LP Company, [e-mail]
Name E-mail Address
1140 Virginia Drive 1140 Virginia Drive
Current Mailing Address Current Street Address
Fort Washington, PA 19034 Fort Washington, PA 19034
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 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.
Type or print name
Signa
1�c.e � \e-ts t jXA+
Title or Authority
Date
I, � &L-(j[ Pr- , a Notary Public of the County of j k"X-51co�t
State of North Carolina, hereby certify that fIl_ _&SS1 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 day of scat 20.?4__
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`,.� Notary
- My commission expires
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