NCC220762_FRO Submitted_20220215

1W_ WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
0=41 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
Environmental Services, Water Quality Division (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name E H,5- 6 9ESCl�
2 Location of land -disturbing activity: Jurisdiction w a ke- c, n i< (Wake Co or Municipality)
Highway/Street i Z 25 1 ,,fi 01, kA Latitude IU 3 5 n 4 G 0 1 Longitude W 79 55' 17
3 Approximate date land -disturbing activity will commence' 0 3 11 5 20 2- 2— n
4 Type of development (residential, commercial, industrial, institutional, etc): Pe 51 PI C r1i f .
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas) 0. 19
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name { ul MEHLUDR16 E-mail Address Of u,i e JoL r al Cchn
UV
Telephone Cell # 5 2 5 - 35-3 - (972, Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
353 -07Z r7yhri%lk met i cor
Name(s) Telephone Fax or E-mail addres
DAIVC t, 121 I n S o 6ovc �� y t
1�IG K�r+ st�� sue I
Current Maili g Address Current Street` ddress
C r I L 2751 ('cu'�4 fo L )
City J State Zip City V State Zip
8 Deed Book No 017 2111 Page No. 00 _' _'7 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)
r M6N r7z_e�
Name E-mail Address
1 Z 16 Ki r, _S�vn &,,PaUc Ni Vc- _i 21 L T t hI S tcn 6hoUc A77, Vc
Current Mailfing Address Current Street'Address
c p f� l (V C 2 751 17 t< -� r 6u (1 27 55)9
City State Zip City State ZIP
Telephone S 5 3 :5-3 677 Z 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:
Iv�r�
Name
E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State Zip
City
Fax Number
State Zip
(b) if the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certif+cate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
P, / /�
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip 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). 1 agree to provide
corrected information should there be any change in the information provided herein
%)T L),L- r F, N ry Qlg2'6
Type or print name
c
Signature
Title or Authority
C 1 j L) 2-
Date
I, A tl. U f-7, a Notary Public of the County of L� [
State of North Carolina, hereby certify that LiA_ r l„I e t l �a�d �� appeared
personally before me this day and being duly swom acknowledged that the above form was executed by him
Witness my hand and notarial seal, this _day of 20 .:
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