NCC222490_FRO Submitted_20220712

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
WAKECounty 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
N„R,,, CAKOUNA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name f ht, O ar r't na+-on
2. Location of land -disturbing activity: Jurisdiction "Ka (Wake Co. or Municipality)
HighwaylStieel Q V-00 Latitude t4 5531$591 Longitude W - I8. 7ZZ135
3. Approximate date land -disturbing activity will commence:a �.
4. Type of development (residential, commercial, industrial, institutional, etc.): ?.4646^4ift 1
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 3.1 ures
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Narnev.eN1 fN N r) ne, E-mail Addressf rW7 11\4 bU66dQ , �on�
Telephone 803-101$- 5-72, Cell# 80-3Fax# _8a3- r798 - 3657
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Vinson
Name() Telephone
P.D. 13a�.11 Z�
Current Mailing Address Current Street Address
90un NC. 27591
City State Zip
City
State
Fax or E-mail address
Zip
8. Deed Book No. Page No, V 1 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):
T►ie CarrMlmn LP .CEO cznrNeW bui 1de(-S. Gorr
Name SA
E-mail Address
Current Mailing Addres
City Q State Zip
Ub Telephone 3Jqs_ C)5-)
Current Street Address
City
State
Fax Number_ 6G3 _�79S_--�)8zI?
Zip

=�w 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
WAKECounty 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
NORM 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
2. Location of land -disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Telephone Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners);
s ; yl
Names) Telephone Fax or E-mail address
P.. &I iA vb
Current Mailing Address Current Street Address
:.Eb \vn N Q'11
City S�t1ate Zip City State Zip
8. Deed Book No. rl Page No. 02A5q 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
Current Mailing Address Current Street Address
City State Zip Clty State Zip
Telephone 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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
cK�zr�•�y � L }
k[AnCv To.<.k o.b� r z N�k'W M Est as- m CV\C_C' lCuk
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
y'j �t�s�- S� ► `�l r o�
City State Zip City State Zip
Telephone 3`34 -��{3- "�A_ 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.
�rv,v c l
Type or print name
Signature
Title or Authorit
Date
QC),
I, 'a'l_�'CL�_ L a Notary Public of the County of U �k
State of Nortpr Carolina, hereby certify that ��LV 1n appeared
personally before me this day and being duly sworn acknowledged that the above form wA executed by him.
Witness my hand and notarial seal, this day of � �� , 20 IXJ_
Notary
My commission expires o� `�