NCC220568_FRO Submitted_20220131

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W -disturbing activity on one or more acres as covered by the Wake
J&
tUNo person may initiate any land
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.
I Project Name
2. Location of land -disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street',U� L& Latitude Longitude
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage —disturbed or uncovered (including off -site utilities and borrow/waste
areas : a "3
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
1: r, 1�1
Name- 65cy\- -_TAiA�,OYA E-mail Address
Telephone9KJ �5VO-72D Cell #C7 Iq I-) cli
C711r^_ !!i2LpFax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
'W&
U 6,n pVyn 6� L-77 ,
_X�k %%) -755
Name(s) Telephone 4ax or E-rriail address
IDI / qc�� —W-6,Ll gj.
Current M 'Zing Address Current Straet Address
U511 t4� Nc W_/&�4 )u- 970 7
City State Zip City State Zip
8. Deed Book No. 18qgq Page No. __ 7q a. 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 inf�rmation):
Name E-3mail Addres-0
Current Mailing Address C t St t Address
�JA AIL
City State Zip City State Zip
Telephone 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
Telephone
E-mail Address
Current Street Address
State 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
7;:a C" ::V� (je r
Typ;;I� ame Title or Authority
Signature Date
I, �� - 14 � " LL — ) t'e_ , a Notary Public of the County of W"' �-c
State of North Carolina, hereby certify that 'Sokn�ve) appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness tpythAHdqpd notarial seal, this S2 day of
'�OT
Seal
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My commission expires /1/31