NCC221749_FRO Submitted_20220506

0 T WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
W=1 SEDIMENTATION POLLUTION CONTROL ACT
A V 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
NOR �1 CAR041.NA 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 Lot 29 Wexford Reserve
2. Location of land -disturbing activity; Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Wexford Pond Way Latitude 35.995240 Longitude-78.545370
3. Approximate date land -disturbing activity will commence: March 1, 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): 0.412 AC.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christopher Davis
E-mail [e-mail]
Telephone Cell # 919-868-4720 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Christopher and Geraldine Reardon
571-606-8383 [e-mail]
Name(s)
Telephone Fax or E-mail address
7 Retriever Trail, Apt 104
Current Mailing Address
Current Street Address
Fredricksburg VA 22406
City State Zip
City State Zip
8. Deed Book No. 018625 Page No.
00676 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):
Grande Manor Homes, LLC.
[e-mail]
Name
E-mail Address
1151 Tarboro Rd
SAME
Current Mailing Address
Current Street Address
Youngsville NC 27596
SAME
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:
Trevor D. Brandt, Attorney [e-mail]
Name
Pa Box 2108
E-mail Address
417 S. Main Street
Current Mailing Address Current Street Address
Wake Forest NC 27588 Wake Forest NC 27587
City State Zip City State Zip
Telephone [phone] Fax Number 919-249-5130
(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.
Christopher Don Davis
Type or grin ame
Signature
Member/Manager
Title or Authority �%
r A- ~O� O']L
Date
Nava -la a Notary Public of the County of
State of North Carolina, hereby certify that G `V'5 tTYTS V- Don Du_6 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 2YkA�I� day of LVL,Y . 20 9-
Amy LWarren ` Notary
NBMRY PUBLIC
Waite County, NC My commission expires ��
My Commission Expires February 2, 2023