NCC216303_FRO Submitted_20211112

O—W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKINo 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 on acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
Environmental 8en/ioae. VVub*r Quality Division. (P|omou type or print and, if the question is not
applicable, place N/A in the blank.)
2. Location ofland-disturbing Jurisdiction Wake Co.
12n5Explorer Trail
(Wake Co. or Municipality)
Longitude
3. Approximate date land -disturbing activity will commence: 1108/21
4` Type of development (nasidentia[commercial, industrial, institutional, ebc.): Residential
[i Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
(l Person tocontact should erosion and sediment control issues arise during land -disturbing
Name James Denton E-mail Address jdentongfuturehomesonine.com
319-422-OS3O
Telephone Cell # Fax#
7 ofRecord (attach accompanied page tolist additional oxvnara}:
Future Homes by Jim Thompson Inc 919-363'4111
Name(s)
1105 Classic Rd
Telephone
1105 Classic Rd
09-363-4044
Current Mailing Address
��--Current Street Address
—
Apex NC 27539 Apex NC2Y539
City State Zip City State Zip
8. Deed Book No. I (A I Page No._Q I a a Provide a copy of the most current deed.
�: 111
1. or Urn(o) who are financially responsible for the land -disturbing e o
non�pnahenm�e|�tofaUresponsible po / on Include -" -�--� (Provide
/u�� � uoeraqueetedmtonnetinn):
Future Homes by Jim Thompson sjones(Pfuturehomesonline.com
Nome ��-------
11O5Classic Rd
Current Mailing Address
Apex NC 27539
City State Zip
Telephone [phone]
E-mail Address �—
----
CurnantGtneetAddresoApex NC 27539
��-----
City
State
Fax Number919-363-4044

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
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
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.
Jim Thompson
Type or print name
President
Title or Authority
10/20/21
Signature Date
1, Sandra Jones , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Jim Thompson 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 o day of lo1Zf 20 Q I
SANDRAft JONES
Notary Public, North Carolina Nota
jelry
Wake County U
My Commission Expires My commission expires 2/1/25