NCC224033_FRO Submitted_20221207

INW. WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
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 f 32-5r] �juM -J Qb
2. Location of land -disturbing activity: Jurisdiction fib r (Wake Co. or Municipality)
Highway/StreetilWi t V Latitude �S [0 ��� Longitudr e I 2qo � 54
3. Approximate date land -disturbing activity will commence: I V I —ao -o- r,� _
4. Type of development (residential, commercial, industrial, institutional, etc.): IC.�S fh�UiF,r
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam E-mail Addres JJ.
C�'
G�flro'�
Telephone � I �f. ���� cell # �I�I : � SO Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Name(s) Telep one Fax or E-mail address
f W v�6 6 a ryy
Current Mailing Address Current Street Address
-b lAI QC �1103
City State Zip
/�
8. Deed Book No. 4 4 1 Page No._
Part B.
�--Cyyi��tyyy
Pu o
State
Zip
Provide a copy of the most current deed.
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):
WXb 611J)�- u)2416 14,
Name J E-mail Address
(� W, lI LmK O.�L
Current Mailing Address Current Street Address
K�Jtlak
City J /} Q� 1State �,�J Zip City StateZip
Q/}r Zip
Telephone " � � - 0 `"� - L gg Fax Number "t - O `'t I �ot5 1

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
Fax Number
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
Tele
E-mail Address
Current Street Address
State 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 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.
COAr
Title or Authority
Date
------------------------------------------------- --------------------- ---------------------------------'--I--------------------------
I, 7i'i'ti� �-a UU ��/1 a Notary Public of the County of
State of North Carolina, hereby certify that `�n ��DOC�G appeared
personally before me this day and being duly sworn acknowled ed that the a ove form was executed by him,
Witness my hand and notarial seal, this day of O G , 20
TRINAA HUDSON
Notary Public otary
Durham Cour%Morth Carolina
My Commission Expires M commission expires (JW d
June 02, 2025 y p

ilt
November 28, 2022
I, Nonna Lewis, as owner of the property located at 13257 Melvin Arnold Road, Raleigh
NC 27613, give Johnny Woody of Woody Built LLC the authority to submit for a permit
and conduct land disturbing activities on this lot in conjunction with the construction of
our personal residence.
&' - 0
y
-A�64-- -JJ
St ature
///-
Date
0-
I, , a Notary Public of the County of
St to of North Carolina, hereby cei ify that �'_L�f� appeared personally
before me this ay of �� Ih , 2022
TRINAA HUDSONA
LAUT%
Notary Public
Durham County, North Carolina
My Commission ExpiresQ
June 02, 2025
otary �
My commission expiresv
919-841-4884 (P) 919-841-4885 (F) www.woodybuilt.com
209 W. Millbrook Road, Raleigh, NC 27609