NCC223708_FRO Submitted_20221101

=�w WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
70 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAUCounty 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 NIA in the blank.)
Part A.
1. Project Name Westmoor Subdivision - Phase 3
2. Location of land -disturbing activity: Jurisdiction Wake Country (Wake Co. or Municipality)
r
Highway/Street Burgwyn Ln Latitude 35.548529 Longitude -78.721801
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): 1. 84
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Weeks E-mall Address
Telephone Cell # 919-880-5809 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Weeks Assnciatas, 1_1_C 919-880-5809 michaei-wsarchitectspa.com
Name(s) Telephone Fax or E-mail address
3305_Durham Drive, Suite 109
Current Mailing Address
IMitMo ►
City State Zip
Current Street Address
City
State
Zip
8. Deed Book No. 011174 Page No. Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive fist of all responsible parties on an attached sheet. Include requested information):
Weeks Associates L.L.0 michael wsarchitects amm
Name E-mail Address
3305_Durham _Drive. Suite 109
Current Mailing Address
_Raleigh _ NC 27603
City State Zip
Current Street Address
City State Zip
Telephone 919-88[j-5809 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
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.
Michael Weeks Managing MPmhPr
Type or p -lint n e Title or Authority
ff --
Signature Date
I, Ngnrg S__Stancii___ , a Notary Public of the County of Jobastml
State of North Carolina, hereby certify that MirhaPl WPPkg _ _ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and.; notarial seat, this day of Fe brufr
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9 Notary
r o': y `�; v. 4Q My commission expires 7-4-2024
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