NCC221884_FRO Submitted_20220607

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
COUNTY sedimentation control: plan have been completed and approved by Wake County Department of
nilti:l 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 Uo r' Nrsr�rfe . �e ffS c5aet a sy del f rro,r•
2. Location of land -disturbing activity: Jurisdiction Wake Co or Municipality)
iPd Jimeos-�On o
Highway/Street Latitude 6_51 Longitude -.? 1&6
3. Approximate date land -disturbing activity will commence: t 1 S Soo r1 us 2a ss t I (e-
4. Type of development (residential, commercial, industrial, institutional, etc.):_ Ecs F cic w*,ja I(
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
a reas):._—___
6. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name jk1evl Sarie'S_ Email Address `�f4 tav� e 5 t� doa�c [1nx��511c ,co'n
Telephone `lq 213 9-Fd Cell # Fax # 1/a �-►ai - C�F'�'
7 Landowner(s) of Record (attach accompanied page to list additional owners):
L1'qne'e 4 Wile.
I DA - 460 -�5 fk i tin 1AfD6j0wP COm-
Name(s Telephone ax or E-mail address
%�!'�' rol7�aY flidgC� d [ r Ft� �•
Current Mailing Address Current Street Address
;wry- vaYTWk-_ Z
City State Zip City State Zip
Deed Book No. 01616,61 —Page Page ND.9*BA gW f3o9 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsibls for the land4stuiNng activity (Provide a
comprehensive list of all responsible parties on an attached sheet, Include requested information):
I?e'� pverr a ast el 5 0+ ie rr
Cz Camara jai 4%. d.:.G i�Mes�riec�dacvq�i\a+Lf�Sn_4,C.anrl
Name E-mail Address
t a _.
Current Mailing Address Current Street Address
Gf a 010 v► 14.C. 925zsa 5>g.4 e�
City State Zip City state Zip
Telephone_ G/I J - 6;2z - I 3 2 5 __ Fax Number 91V — �62 I �- _15f

(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 State Zip
Telephon
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 E-mail Address
Current Mailing Address
City
State Zip
Current Street Address
City
Telephone_ �, - Fax N
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.
�'vi r1 o e S i ce: A V, %dotrRau e r
Type or pri name Title or Authority
_ - % E- ; �
Signature Date
��[[ f ' .p ii a Notary Public of the County of �
I, J..` � � l i � t V Tom � oy - ---��--
State of North Carolina, hereby certify that - .j av` _ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial sea[, this D b day of "i . , 20 1 2
�,p�gti�nntpy%
Od !
•� 'ice f r My commission expires !�
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