NCC221072_FRO Submitted_20220316

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WAKE
COUNTY
NORTH CA ROL.I NA
Part A.
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
County Unified Development Ordinance before this form and an acceptable erosion and
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 N/A in the blank.)
Project
2. Location of land -disturbing activity: Jurisdiction V V (Wake Co. or Municipality)
Highway/Street �>(�m i' v ' Latitude �6'1 4� a Longitude — ` 3 d �P clo
3. Approximate date land -disturbing activity will commence: � ✓q 1 �i 2021 II __
4. Type of development (residential, commercial, industrial, institutional, etc.): %C S I d Cat I
5. Total acres e� disturbed or uncovered (including off -site utilities and borrow/waste
areas): +'
6. Person
�tto�contact should erosion and sediment control issues arise during land -disturbing activity:
Name V VIDn2CA 0k' "C--' E-mail Address �UhZur MN), tw"
Telephone l� 2l Le 7% �J —Cell # Fax # 60 3 2 J
7. Landowner(s) of Record (attach accompanied page to list additional owners):
r-7 'D waAA4- -rn C , q t q _� 9 � 2,- S-4 (P rn_o n kes rn4 ') . o-n
Name(s) Telephone Fax or E-mail address
%1 Pat qu kyo � S6_4/-V�
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. 8� 3 Page No. 014 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 information):
Name E-mail Address
alb �0ut aVILVi'v� C6
Current Mailing Address J
i (In I� G Z� (t 10
City State Zip
Telephone " 6 � Z 5 4 `/ .P
Current Street Address
City
State
Fax Number q I q b 00 5 L) 3
Zip

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: i
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 E-mail Address
Current Mailing 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.
Type or print name 4 Title or Authority
Siafiature
Notary
State of North Carolina, hereby certify that -::-'
personally before me this day and being duly sworn ac
Witness my hand and notarial seal, this jj'4day of
,
R 0 JJAN
� N '
NOTARY _
PUBLIC
09jsa2o23
%FCOUN�
Date � LA I � �
the County of ZIV
appeared
ed that the ab ve fo xecuted by him.
Aju a Jot 20_
Notary
My commission expires t;�Xno liq