NCC220781_FRO Submitted_20220216

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
- 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 CAKOHNA 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 233 Hasentree
2. Location of land -disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street_ 7005 Hasentree Way Latitude 35.985900- Longitude-78.589460
3. Approximate date land -disturbing activity will commence: 03/01/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including _ off -site utilities and borrow/waste
areas): 0.482
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Russotti E-mail Address [e-mail]
Telephone [phone] Cell # 919-360-6099 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
EXETER BUILDING COMPANY LLC N/A
Name(s)
900 Ridgefield Drive STE 50
Telephone
900 Ridgefield Drive STE 50
N/A
Fax or E-mail address
Current Mailing Address
Current Street Address
RALEIGH NC
27609
RALEIGH, NC 27609
City State
Zip
City State Zip
8. Deed Book No. 018749
Page No.
01526 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):
CX67E-p 8y4 Vg,.Vy
LZZ
[e-mail]
Name 9E-mail
Address
900 Ridgefield Drive STE 50
900 Ridgefield Drive STE 50
Current Mailing Address
Current Street Address
Raleigh NC
27609
Raleigh NC 27609
City State
Zip
City State Zip
Telephone [phone]
Fax Number N/A

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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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.
Alexander Yost Managing Member
Type or p ' am Titl or uthority
L�Zz
S icTnaNre to
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a Notary Public of the County of A k E
State of North Carolina, hereby certify that ,AXo-x--a%.. goyk 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 1,$ P-day of �5'74AA/ 0 A P-
JEREMY GAGE
� 4MarPublic - North Carolina
"eary Wake County
My Commission Expires Apr 3, 2024
commission expires `t