NCC222019_FRO Submitted_20220531

slw.. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W=7 No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKE
County 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
NORTH CAROLIN. Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name L de :
2. Location of land -disturbing activity: Jurisdiction Wa Ve C-`' • (Wake Co. or Municipality)
Highway/Streets 4t u4jkatitude 3S�UZ_ I 1� tl 0 Longitude— Les—&S�O
3. Approximate date land -disturbing activity will commence: Q loll Z e ZLZL
4. Type of development (residential, commercial, industrial, institutional, etc.): 5 c(e n I
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): . % 5-
Person to contact should erosion andsediment control issues arise during land / -disturbing activity:
Name l (. (�� �ie d l 11 / E-mail Address C (�(kl/'t i A. I I c tl C. / l- C. 0 M
Telephone 1 G- b 1r 8 6 0 Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�Al;jd Undo 1,-.l i M- r- UyCe v
Wiame(s) // ;� Telephone [, Fax or E-mail address
Current Mailing Address Current Street Address
City ' State Zip City 61 State Zip
u zZ
3. Deed Book No. Page No.1W qO Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
compr eTe's of all responsibl parties on an attached sheet. Include requested information):
uhc�e�-7' I (PAC 1"t1. C6 r�
Name E-mail Address
Current Mailing Address
(I kei fb/t 7�76
City - State Zip
Telephone 9< y & �- & G- b
��� ,S7rnCJ/G6� �/
Cu ent Street Address
C_
City State Zip
Fax Number

(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 /
l 26 � 1Tb /�P rnir i {'1 _
Current Mailing Address
City State Zip
�j
Telephone 9� 7 - 15 /0 " y � 3
E-mail Address
2 L S S4yA e_/"1 o e-P_ t a/ e
Current Street Address
,4tt,,� A)C d2-7ce a3
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
Telephon
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
correcV4 information phould there be any change in the information provided herein.
Title or Authority
Date
4A'Ah0Ve_, a Notary Publi of the Co my f
, ohn`(1 vh
State of North Carolina, herebycertify that (' ;U UN'o hI' I appeared
personally before me this day and being idyK
orn acknowledged that the above firm was executed by him.
Witness my hand and notarial seal, this dayof , 20 AIL
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_` �c.,. OTAR ��� Notary
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