NCC220941_FRO Submitted_20220303

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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
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 Buckhorn Duncan OLt5o a,! 606fi M k
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Buckhorn Duncan Rd Latitude 35.5955 Longitude -78.8705
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 26.02
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Young E-mail Address aeorge.you ng _mattamycorp.com
Telephone Cell # 919-625-9546 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Buckhorn VI LLC
Name(s) Telephone Fax or E-mail address
2721 Oxford Bluff Drive 2721 Oxford Bluff Drive
Current Mailing Address Current Street Address
Wake Forest, NC 27587 Wake Forest, NC 27587
City State Zip City State Zip
8. Deed Book No. 018130 Page No. 00955 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):
Mattamy Homes - George Young [e-mail]
Name E-mail Address
11000 Regency Parkway, Suite 110 11000 Regency Parkway, Suite 110
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State Zip City State Zip
Telephone [phone] 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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone Fax Num
(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:
Mattamy Homes - George Youn
Name of Registered Agent
11000 Regency Parkway, Suite 110
Current Mailing Address
Cary, NC 27518
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
11000 Regency Parkway, Suite 110
Current Street Address
Cary, NC 27518
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.
Type or
Sign
,A- If (/ t C.P
Title or Authority
Date
a Notary Public of the County of J&KM570N
State of North Carolina, hereby certify that ` lfa� 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 Aay of 20
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