NCC220624_FRO Submitted_20220211

RIM-0 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=7_ SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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 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 Hollybrook - Athletic Club
2. Location of land -disturbing activity: Jurisdiction Town of Wendell (Wake Co. or Municipality)
Highway/Street S. Hollybrook Rd. Latitude 35d45'51"N Longitude 78d21'35"W
3. Approximate date land -disturbing activity will commence: 02/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.70
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Fred Smith E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Smith -Edwards, LLC
Name(s) Telephone Fax or E-mail address
2102 PRITCHARD ROAD 2102 PRITCHARD ROAD
Current Mailing Address Current Street Address
CLAYTON, NC 27527 CLAYTON, NC 27527
City State Zip City State Zip
8. Deed Book No. 12538 Page No. 1623 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). -
Fred Smith [e-mail]
Name E-mail Address
2102 PRITCHARD ROAD 2102 PRITCHARD ROAD
Current Mailing Address Current Street Address
CLAYTON, NC 27527 CLAYTON, NC 27527
City State Zip City
Telephone [phone] Fax Number.
State Zip

(a) If the Financially Responsible Party is not a resident of Wake County, identify a designated age
Wake County to receive any notice, process, pleading in any action or legal proceeding arisin of any
matter relating to the Wake County Erosion and Sedimentation Control Ordina and/or Land
Disturbance Permit:
Name
Current Mailing Address
E-mail
Current Street Address
City State Zip City State Zip
TeleptParl— Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business u an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financial) sponsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Adore
Current Mailing Address Current Street Address
City tate Zip City State Zip
Teleph 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.
Type or print n
Signature
-------------
Member
Title or Authority
09/09/2021
Date
I, '�_Qr1y �C_ s , a Notary Public of the County of
State of North Carolina, hereby certify that �t-L j ZM,A-� , :Z-S' • 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, thisgf day of 'S�MEn1 -V_20 a- I
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Seal `� �OT,q,Q.02'
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My commission expires 03 Iag 1. Q5