NCC222505_FRO Submitted_20220714

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
A V No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
KE, County Unified Development Ordinance before this form and an acceptable erosion and
WA
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROI.INA 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 Granite Crest - Phase IVb
2. Location of land -disturbing activity: Jurisdiction Town of ROlesville _ (Wake Co. or Municipality)
Highway/Street Smoke Willow Way Latitude 35.93 Longitude -78.47
3. Approximate date land -disturbing activity will commence: 05/15/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ 4.0
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Hal Perry E-mail Address halperry _remc.us
Telephone [phone] Cell # Fax #
7 Landowner(s) of Record (attach accompanied page to list additional owners):
REAL ESTATE MARKETING & CONSULTING, INC (91 9) 865-9918 [e-mail]
Name(s) Telephone Fax or E-mail address
6200 Falls of Neuse Road: Suite 102 6200 Falls of Neuse Road; Suite 102
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
8. Deed Book No. 016388 Page No.1133 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):
REAL ESTATE MARKETING & CONSULTING, INC [e-mail]
Name E-mail Address
6200 Falls of Neuse Road; Suite 102 6200 Falls of Neuse Road; Suite 102
Current Mailing Address Current Street Address
Raleigh NC 27609 Ralei h NC 27609
City State Zip City State Zip
Telephone[phone] 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
E-mail Address
City Zip City
Teleph _ _ Fax Number
Address
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:
Name of Registered Agent
Current Mailing Address
City
E-mail Address
rrent Street Address
Zip 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
corrected information should there be any change in the information provided herein.
Q/ 10 r czeg l �ls;�r�7` —
Type or print na //ee� Title or Authority
Signature % Date
R4/ r q __. a Notary Public of the County of
State of North Carolina, hereby certify that _HOJ Rrr appeared
personally before me this day and being duly sworn acknowledge that the above form was executed by him_
Witness my hand and notarial seal, this I5day of , 20 <i ,
Notary
Seal 2 e S �rc �
My commission expires a� J00