HomeMy WebLinkAboutNCC221760_FRO Submitted_20220526I RE !
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NORTH CAROIFNA
Part A.
WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 duality Division. (Please type or print and, if the question is not
applicable, place NIA In the blank.)
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3. Approximate date land -disturbing activity will commence: /
4. Type of development residential commercial, industrial, institutional, etc.):__r__
5. Total acreage disturbed or uncovered (including off -site utilities and borrow&aste
areas): / .
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name G r E-mail Address
�s.�HJ RrOF' Ss+e t,c�ti n t � O W � pywS, co.v�
Telephone Cell # 6)lq fnffi 1313 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
a
Names)
Current Mailing Address
�; 3A 5-03a47
City State Zip
Telephone Fax or E-mail address
Current Street Address
City State Zip
8, Deed Book No. 8?LI- Page No. law 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):
Name E-mail Address
iyo I I Str�
Current Mailing Address Current Street Address
d2�'.<�,d I-4 e_
City State Zip City State Zip
Telephone 1 �`7� 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
City Slate Zip
Telephone
E-mail Address
Current Street Address
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 zip
Telephone
E-mail Address
Current Street Address
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.
Cl/1!!rr,y'
Type or print name Title or Aulhori
nature Date
State of North Carolina, hereby certify that ) 1 }jNoi.,j., w(+:6Lz,c_-j 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 HA Pm , 20 Z Z.
DZULA�L�ViAo
TERESA C SMITH Notary _
Se OTARY PUBLIC
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FOANKLIN COUNTY My commission expires 1 D �DLS
STATE OF NORTH CAROLINA