NCC217187_FRO Submitted_20220104

WAKE COUNTY FINANCIAL RESPONSiBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
��j No person may initiate any land -disturbing activity on One or more acres a$ covered by the Wake
VY� County Unified Development Ordinance before this form and an acceptable erosion and
COUNT) sedimentation control plan have been completed and approved by Wake County Department of
Environmental Services, Water Quality Division (Please type or pnnt and, if the question is not
applicable, place NIA in the blank.)
Part A-
i Protect Nary
Location of land -disturbing aunty- Jurisdiction L L flNake Co. or MurntipalRyy
Fi�ghvray?5trcer I �a Q�. Latitude Z �i 0 Longitude ' 7 0. 3�Ips`L d
3. Approximate date land-dsturbing acttvrty wiii continence. i [ . } . Z l �y
4. Type of aeveiopmcni (residential. corrimergal. industrial, inststutional, etc.);
5. Total acreage disturbed ar uncovered [%neruding off -site ubldtes and borrowtwastn
areas): ► Z
6- Person to contact should erosion and sediment control issues arise during land -disturbing activity,
Name �`` a ^ U�s 4 E-mail A Wress �r:�• a o ca l c r.rr .,� .Corti
Telephoned ��r 37 �( Cell # Fax
ri
Landowner(O of Record ;attach accompanied page to list additional owners!-
Narne(s) Telephone
4
Current Maffing Address Current Street Address
cgr� V� Z��i3
city state 70
_ city state
Fax or E-matt address
Lp
8 Deed Book No ��Zt Page No, Cie 2 3�7 Provide a copy of tree most current deed.
Part B_
t. Personfsl or firm(s) who are frnanc tiny responsible for the land -disturbing activity (Provide a
comprehensive list of aii responsible parlies on an attached sheet- Include requested infit)rrnation)
!Name ram_ E-mail Address
_ -z(2 - - "': ! ! , /
Current Mailiftj Address
City I State Zip
Telephone ��G z9i �?f 1
Current Street Address
city State Zo
Fax N umber N / /�

Z- (a) if the Financially Responsible Party is not a resident of Wake County. rdcntrfy a designated agent in
Wake County to re erne any notice, process, pieading in any action or legal proceeding arising out of any
matter relating to !be Wake County Eroston and Sedimentation Control Ordinance and, -'Or Land
DistuMance Permit.
Name
E-mail Address
Current Mailing Address Current Street Address
City Smote Zip City state Zip
Tefthone Fax number
ibj if the Financially Responsible party ;s a Partnership or other person engaging in business under an
asS med name, sthch 7 copy of the Certiiicata of Assumed Name. if the Financially Responsible
Party is a Corporation, give name and street addivss of the Registered Agent
Name or Register~ Agent E-naii AUCKess
Current Maiiing Address Current Street Address
City state Zip City State Zp
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me iinder oath {This form must be signed by the Financiaily Responsible Person if an individual
or his attorney -in -fad. or if not an individual. by an officer, director, partner, or registered agent wrath
the authority to execute instruments for the Financially Responsib}e Person) i agree to provide
corrected information should there tie any change in the information provided herein
U l ,n+i� `
Type or pnpt- m
signature
f
Title or Authority
z
Date
1. _ Ck ol _ flCf e--I . a Notary Public of the County of
State of North Carolina, hereby certify that CC 07 -xie-11 _ appeared
w
personalty before me this day and being duly swam aoknokdged that the above form was executed by him.
witness my hand and noitanat seal, this _day of eW - 24.2
r n L •'
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