NCC221642_FRO Submitted_20220501

madmippp— 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
rWAKICounty Unified Development Ordinance before this form and an acceptable erosion and
77 sedimentation control plan have been completed and approved by Wake County Department of
COUNTY
NOR I H C ARM 1 NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
__1 applicable, place N/A in the blank.)
U-n��
1. Project Name Norwood Ridge Lnts| h 9 /2 15 18
2. Location ofland-disturbing activity: Jurisdiction Wobc County (Wake Co. nrMunicipality)
Highway/Street I4Il2Norwood 82l Latitude 354416 Longitude -7&6556
3. Approximate date land -disturbing activity will commence: Feb 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
G. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Sherman E-mail Address [e-mail]
Telephone 919-460l403 Cell # Fex#
7. )ofRecord (attach accompanied page holist additional ownern):
0540Cnlouoade Center Dr, StolO5
Current Mailing Address
Raleigh, NC 27615 —
City State Zip
i. Deed Book No. 018575
Telephone Fax orE-mail address
0540Colonnade Center Dr, 3tcl05
Current Street Address
Raleigh, NC 27615
City State Zip
01486 Provide acopy ofthe most current deed.
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):
1941 Evans Rd 1941 Evans Rd
6u_rrent Mailing Address Current Street Address
Cary, NC 27513 Cary, NC 27513
City State Zip City State
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:
NA
Current Mailing Address
City
U=
E-mail Address
Current Street Address
State Zip City State Zip
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
City State
Telephone
E-mail Address
Current Street Address
Zip City
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). I agree to provide
corrected information should there be any change in the information provided herein.
Type of print name Title or Authority
Signature Date
1, , a Notary Public of the County of
State of North Carolina, hereby certify that 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 — � �' day of
0 Y�0 �?'L:%
Notary
Seal
I
on expires 0