NCC222253_FRO Submitted_20220621

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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
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 —_ Lot 3 Churchill Associates
_--_----_ — — —_—
2. Location of land -disturbing activity: Jurisdiction Wake County -� --_`__ (Wake Co. or Municipality)
Highway/Street_Latitude—__Longitude=
9604 Zest Ln. 36 042813 March 1 2022
78.635326
--------
3. Approximate date land -disturbing activity will commence: —__—--__-----__—
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):-._ 0.885_AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
to her [e-mail]
Chris
Name � DavisD -- E-mail Address---- __---
Telephone------------_ Cell # _ 919-868_4720 --- Fax # —_
7. Landowner(s) of Record (attach accompanied page to list additional owners):
_ Chad and Jennifer Ronyetz— ——419-356-9519----- [e-mail]
Name(s) Telephone Fax or E-mail address
1729 River Run _C_t. SAME
Current Mailing Address —� -- Current Street Address Jv--_--_---_
Franklinton NC 27525 SAME
---------------- ---- — ----------
City State Zip City State Zip
8. Deed Book No._ 018038 ---Page No._ 00013 —_—_ 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-919'868-4720�� - - 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 E-mail Address
PC Box 2108 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 Member/Manager
Type or pnn name
Type
Title or Authority
--ir - a. -ate
Date
I, ,. UVO, V V-f A a Notary Public of the County ofy K
State of North Carolina, hereby certify that C10VI5 t " k,( V- Don CAt/is 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 CJ�/-�-,� 20 ��
Amy L Warren
NEgARY PUBLIC
Ware County, NC
My Commission Expires Fgbfuary 2, 2023
Notary
My commission expires���