NCC224110_FRO Submitted_20221220

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
lx�w. 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
Environmental Services, Water Quality Division. (Please type or print and if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Rivers Edge Apartments
2. Location of land -disturbing activity: Jurisdiction Town of Kni htdale (Wake Co. or Municipality)
Highway/Street.0 New Bern Ave. US 64 Bus, Latitude 35.794333 Longitude-78.536156
3. Approximate date land -disturbing activity will commence. TBD
4. Type of development (residential, commercial, industrial, institutional, etc.: Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 18.6
6_ Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff Shifflett E-mail Address ishiffiett castled com
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners): (See attached)
Parkway Properties Group, LLC 919-462-0775 919 462-9460
Name(s) Telephone Fax or E-mail address
1000 Darrin ton Drive Ste. 105
Current Mailing Address Current Street Address
Ca NC 27513
City State Zip City
State
up
8. Deed Book No 11743 5977. 79Tf.11448 17351,17aiG Page No. 036079T 915 616.83 5556 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):
Kni htdale Associates LP achenbach castled .cam
Name E-mail Address
230 Court S uare Suite 202
Current Mailing Address Current Street Address
Charlottesville VA 22902
City State Zip City State Zip
Telephone [phone] 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 an y
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Corporation Service Comoar.y
Name
Current Mailing Address
City
Telephone
mike,[e-mail]
E-mail Address
2626 Glenwood Ave, Suite 550
Current Street Address
Raleigh, NC
State Zip City
800-344-0350
Fax Number
State
276C8
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:
Mike Angeline (acct #8250868)
Name of Registered Agent
Current Mailing Address
City
State ZIP
Telephone [phone]
[e-mail]
E-mail Address
2626 Glenwood Ave, Suite 550
Current Street Address
Raleigh NC 27608
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.
Andy McGin Mans er
Type or print name Title or Authority,74Z
Z
f� Z
Signature Date
a Notary Public of the County of
State of Virginia, hereby certify that _ n J` M G. appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
ri J 2_ �
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Witness my hand and notarlal seal, this day of ✓ 20
Notary
STEPH� CLAY �� �-
NOT EUC My commission expires
REG. #70%16
LWomiookwEALTH OF vIRGINIA
µMl5SioN E7tPIRE5 m RCH 34, 2023