NCC223836_FRO Submitted_20221116

mw� WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
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 I' Awk &APrA4._P14.3
Location of land -disturbing activity: Jurisdiction SAKE (Wake Co. or Municipality)
Highway/Street f32ogiK r ieour LP Latitude �� '3 2`f 1 ,9 L Longitude — 7�3',(! Z2,o4'
3. Approximate date land -disturbing activity will commence: 01 /o 1 /70 Z 3
4. Type of development (residential, commercial, industrial, institutional, etc.): 2E5 tO t:,JT r X
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):__, q
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name, AlegQ 15L. <reVAg f E-mail Address S T'6tJAR7'PE10_ AOL.601A
Telephone -7 SS Cell #
Fax # 414-779 -/GG I
7. Landowner(s) of Record (attach accompanied page to list additional owners):
cA t5yE.jjt.J g__ peye-L-ope2s G 3g — z 2 3 r A"4r a`S.ev^
Name(s) Telephone Fax or E-mail address
40 PtZur-RG 5sraE PAr2V_1aAY
Current Mailing Address
p N c i r 2- - �J C-- _ 2 7S�a I
City State Zip
Current Street Address
City
State
Zip
Deed Book No. I 10 i_7 Page No. �.�3 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 list of all responsible parties on an attached sheet. Include requested information):
Gi4F�E�liJ _ {}g��cnP�Q_S 5'rt 10Naz46apRo0Et�Yr�S.Gn/'1
Name E-mail Address
-f PI2o('QCSSr✓E PA2 t ^-/ yu ed ) _
Current Mailing Address Current Street Address
A+.-) 6 11 4 0 e--.-_�'ca I _
City State .Zip City
State
Telephone 9 Jq — �_77--2231 Fax Number $ � LP39 ty9 V 1
ME

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.
Type or print name Title or Authority
Date
1, ( B. 9060 , a Notary Public of the County of Hotmet+
State of North Carolina, hereby certify that QV42S W. lw�m 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 112 day of "Lr�,f 2027
VIC rgFi H BUCIOe2
M
Notary Public, North Catalina 2z- �2�720/11:::�_V
Harnett County Np ary op
Sty Commission Expires ��"`
January PNW 2026 M commission ex ices �1�21�1 0 2c)