NCC216021_FRO Submitted_20211029

WAKE 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
WACounty 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 CAROL]NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
I. project Name Carlton Pointe (Lot 253)
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street701JameshurstWay (Lot 253) Latitude 35.903851 Longitude-78•478089
3. Approximate date land -disturbing activity will commence: 30 days
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.305
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Laurie Chamberlain E-mail Address [e-mail]
Telephone Cell # 910-494-1348 Fax #
7
Landowner(s) of Record (attach accompanied page to list additional owners):
JSJ Builders, Inc. 910-438-0796
Name(s) Telephone
1135 Robeson Street 1135 Robeson Street
Current Mailing Address Current Street Address
kevinshortridge@gmalwom
Fax or E-mail address
Fayetteville NC 28305 Fayetteville NC 28305
City State Zip City State Zip
8. Deed Book No. 11427 Page No. 882 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):
JSJ Builders, Inc. [e-mail]
Name E-mail Address
1135 Robeson Street
Current Mailing Address
1135 Robeson Street
Current Street Address
Fayetteville NC 28305 Fayetteville NC 28305
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:
Jim Allen
[e-mail]
Name
E-mail Address
5000 Falls of Neuse Road, Suite 100
5000 Falls of Neuse Road, Suite 100
Current Mailing Address
Current Street Address
Raleigh NC 27607
Raleigh NC 27607
City State Zip
City State Zip
Telephone[phone]
Fax Number919-653-4946
(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.
Kevin Shortridge Vice President
Typ nt ant Title or Authority
7129/2021
Signature Date
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I, 1 L! F'G! A r -TVou f a Notary Public of the County of
State of North Carolina, hereby certify that F_ 6111 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial sea[, this day of l(� 20 .y1
Notary
Seal
�tirll t,!+1'
My commission expires