NCC223922_FRO Submitted_20221123

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
NORIt, (:,ROIINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Project Name Caddy Road South
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street US 401 and Caddy Rd Latitude 35.667834 Longitude-78.694720
3. Approximate date land -disturbing activity will commence: July 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 8.50 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barrett Blackburn, P.E. E-mail Address bbb(a)cambridgeprop.com
Telephone [phone] Cell # 704-661-1893 Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Cambridae-Caddy. LLC 704-661-1893 [e-mail]
Name(s) Telephone Fax or E-mail address
831 E. Morehead Street, Ste 245 831 E. Morehead Street, Ste 245
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
8. Deed Book No. 19036 Page No. 159-162 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):
Cambridae-Caddy. LLC bbbacarnbridaeprop.com
Name E-mail Address
831 E. Morehead Street, Ste 245 831 E. Morehead Street, Ste 245
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number 704-333-2394

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 State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current 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.
John J. Priester, Jr. Manager
Type or print name Title or Authority
Vgnaturx Date
I, 7 YV11 44 L. W 1 uS a Notary Public of the County ofb�Q
State of North Carolina, hereby certify that 570"YN 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 64'11 day of Twt 2022._
Notary
My commission expires 74per• 2$ 2021