NCC222417_FRO Submitted_20220705

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
NORTH CAROLINA 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 Trinity Forest Lots 3, 5, 6
2. Location of land -disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street Bishop Pine Ln Latitude 36.016418 Longitude-78.619422
3. Approximate date land -disturbing activity will commence: 5/20/22
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.9
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Kerul E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Braswell Custom Homes Inc 919-266-9360
Name(s)
PO Box 40159
Current Mailing Address
Raleigh NC 27629
City State
8. Deed Book No. 018898
Part B.
Telephone
Current Street Address
Zip City
Page No. 00428
State
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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):
Braswell Custom Homes Inc [e-mail]
Name E-mail Address
PO Box 40159
Current Mailing Address Current Street Address
Raleigh NC 27629
City State Zip City State Zip
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 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.
Type or print name
Signature
Title or Authority
F/I 9 /Z"C7
Date
I, \ a Notary Public of the County of
State of North Carolina, hereby certify that NVL3(A2�" ;(\� ` appeared
personally before me this day and being duly sworn ackno ledged that the above form was executed by him.
Witness my hand and notarial seal, this day of 6, 2(l
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