NCC223757_FRO Submitted_20221123

M—W
WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
T �� No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
W/�/ County 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
ho�Trt enRoirM� Environmental Services, Water Quality Division. Please
applicable, place N/A in the blank.) ( type or print and, if the question is not
Part A.
1, Project Name vS 31 �\t C":; v%LVXNdN
2. Location of land -disturbing activity: Jurisdiction
(Wake Co. or Municipality)
Highway/Street (�`1'�� NI&S CO*ST Latitude `�5.0 (071\0 Longitude
3. Approximate date land -disturbing activity will commence: `� � �00,69D..
4. Type of development (residential, commercial, industrial, institutional, etc.) _1
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): d.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name__ pAbpi pt�ty� - �, � AC _tZ E-mail Address
SME�Q..�ctiyG? C�i�P``S_NC coM
Telephone �
Cell # �3�s, - ,` - 4�L`/id. Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
7�S � i�MGS U.. L �� C� — �.`�, — L13'ia.. p.� t�Zca�
Names Telephone
Fax or E-mail address
}..Current Mailing Address — Current Street Address
C (ty \LL1 KM 03 c�C ij� j
State ,Zip City State
Zip
8. Deed Book No. C>\ \L1Q Page No. U`c t 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):
l S l-i-C. _ t416C-nN�Zrs
Name — QS_ 1 NL c�,f.
E MWII Address
Current Mailing Address
Current Street Address
t�AUV-Llu
City State Tls -- t "tu`�c N �30
ip City State Zip
Telephone Cfl - `b'13 -Lt y Fax Number ;� e

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 --
1 �Mailj��gAdd�ressCurrent
City State
zip
Telephone
E-mail Address
1�
Current Street Address
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 dA
City State
Telephone
E-mail Address
Current Street Ad -dress
Zip City
Fax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This for 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
Sig a ure
ErC •
Title or Authority
()--q - i
Date
--------------------------
i,
a Notary Public of the County of
state of North Carolina, hereby certify that f
personally before me this day and being duly sworn ..Jueffl CAW acknowledg d that the above rmw appeared
as executed by him.
Witness WO t1*116,49d notarial seal, this IS of r�
DA Md lei 20 ZL
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r$� Notary
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