NCC216121_FRO Submitted_20211104

=�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
70. SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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 2620 Tealin Ln. Single -Lot Sediment & Erosion Control Plan
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street 2620 Tealin Ln. Latitude 35' 42' 44" Longitude 78' 43' 45.30"
3. Approximate date land -disturbing activity will commence: October 15, 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): 0.68 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin B. Merta
Telephone
E-mail Address kevin(@cehomesnc.com
Cell # 919-588-0044 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Custom Estate Development LLC
Name(s)
205 W. Millbrook Rd. Suite 100
Current Mailing Address
40167'%1:11I111M
Telephone
205 W. Millbrook Rd. Suite 100
Current Street Address
[e-mail]
Fax or E-mail address
Raleigh NC 27609-4492 Raleigh NC 27609-4492
City State Zip City State Zip
8. Deed Book No. 018338 Page No. 02669 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):
Kevin B. Merta, President, Custom Estate Homes, Inc. [e-mail]
Name E-mail Address
811 Manchester Dr.
Current Mailing Address
811 Manchester Dr.
Current Street Address
Raleigh NC 27609-5148 Raleigh NC 27609-5148
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 State
Telephone.
E-mail Address
Current Street Address
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:
Kevin B. Merta, President - Custom Estate Homes, Inc. [e-mail]
Name of Registered Agent E-mail Address
811 Manchester Dr.
Current Mailing Address
811 Manchester Dr.
Current Street Address
Raleigh NC 27609-5148 Raleigh NC 27609-5148
City State Zip City State Zip
Telephone [phone] 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 B. Merta
Type or print name
Sig
President, Custom Estate Homes, Inc.
Title or Authority
A - o� r,i
Date
a Notary Public of the County of
J-
`
State of North Carolina, hereby certify that /`jc �rti /� / lei, appeared
personally before me this day and being duly sworn ack wledged that the above form was executed by him.
Witness my hand and notarial seal, this 0_ day off. 120 t
Notary
PATRI IMERRITT
Notary Public My commission expires
Wake Co., North Carolina
My Commission Expires Sept. 05, 2022