NCC221229_FRO Submitted_20220331

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
IN, 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 Allen Park Phase 1
2. Location of land -disturbing activity: Jurisdiction Knightdale (Wake Co. or Municipality)
Highway/Street Old Milburnie Rd Latitude W 78°30'51.04" Longitude N 35°49'79.59"
3. Approximate date land -disturbing activity will commence: 03/15/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 37 AC
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name At; r•+.3 I �,,/jA6st�t$i � � E-mail Address Ar i 4'V @ '#A �e � �� • ep'
Telephone 919 310 Z. Cell # `T)9 $!off 3102 Fax # I?�
7. Landowner(s) of Record (attach accompanied page to list additional owners):
01Ino Park, LLB. 919 134AS 31a2-- briAt e- NA4ef�;.car+�
Name(s) Telephone Fax or E-mail address
50I'm 3 Soto Ad.;'J S4,re,t� , S �C_ 3n z—,
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. C31 bfJ(o ( Page No. O2&K '0241IProvide a copy of the most current deeee�
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):
f�k`et-a Paek LLC oup'- tl:. tom
Name E-mail Address
� f Q
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 91g '566% 3102 Fax Number )6.

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 l 1 p
&'RN riraN (R A)A'AV-- 1 �' • CO✓+'1
Name ,y I pp E-mail Address
1903 W. l�arrisF,�J k�1C. Si�lDj ^ /903 ,)•1_Ltr;sa'6l
Current Mailing Address Current Street Address
Crate,.,,_ N C at• w /V C. ZJIS�
City State Zip City State Zip
Telephone L91z1 $(ate 3laZ 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.
;w der 5 ck LLL AU �l 1)e1 -1&J - 1_` Cn4tl
Type rint name Title or Authority
4�� - r
Signature
1--30 - Zoe --
Date
I, 7: �,.�, ,rf 1VAWVV a Notary Public of the County of -��_
State of North Carolina, hereby certify that Nri jxj `7 - MA SSeAX'� �. �.. _ appeared
personally before me this day and being duly sworn acknowledged that the above formJ'ivas executed by him.
Witness my hand and notarial seal, this 3�� day of "SikndLzk�, , 20 22-
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F �.= Not
My commission expires
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