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HomeMy WebLinkAboutNCC221760_FRO Submitted_20220526I RE ! WA17CE OU 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.) 4 �-s t Po 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 mp FOANKLIN COUNTY My commission expires 1 D �DLS STATE OF NORTH CAROLINA