HomeMy WebLinkAboutNCC230067_FRO Submitted_20230111IV WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l 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
NORM «V011NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. `Q
1. Project Name 16
2. Location of land -disturbing activity: Jurisdiction VyC_ (Wake Co. or Municipality)
Highway/Street ("VCl /4/VJf%<3Latitude as• (� � Longitude — -7 $ • �3Z q0
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0 v 1J0
6. Person to
ntact should(erosion
nanndd sediment control issues arise
/;during land -disturbing activity:
,,f n
Name— r V ��CJ�, �-1 co E-mail AddresSJ6SW . rfl*V'ok_fJ-F
Telephone Cell # V LQ RX e2j7 4Fax # C �
7. X;r(s) of Record (attach accompanied page to list additional owners):
ame(s) Telephone Fax or E-mail address
61-340
Cm � r s mattiv
Cur nt Mailing Address Current Street Address
�QLQh Ne 4` 15- lI
City State Zip City State
8. Deed Book No. OI (v73Z Page No. aZ)7/6 -607�v de a copy of the most current deed.
Part B.
Zip
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide
comprehensive list 140
ll responsible p rties on an attached sheet. Include requested information):
�I &fin k,_�Gsan
Name _ E-mail Address
at (a3 � f
Mailing Address
City v (( /r State Zip
Zip
Telephone 00 �Jl (Lp
Current Street Address
City
State
Fax Number 0'/ il
Zip
caul
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
corre ed information sho Id there be any change in the information provided herein.
),q 3 M A,
"to'
Tyft ox print name I Title or Authority
atd"re Date
I, Z0CIA e J!� fV\g t ct a Notary Public of the County of V 6"Q.,
State of North Carolina, hereby certify that la,'C, 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 tc�
day of MO,,W 20 Z i
Notary
My commission expires 0D A i Z. C Zd
MW_
WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
0 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 CARO(NA 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
d6 a,-& 111
2. Location of land -disturbing
activity: urisdiction (Wake Co. or Municipality)
Highway/Street V,l Latitude s • ��� Longitude ��7J •���
3. Approximate date land -disturbing activity will commence: itDecernbAq— to o?QD)
4. Type of development (residential, commercial, industrial, institutional,
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ , g T
w
6. Perso3nn
contact shOal
ould erosion
and sediment control issues arise during land -disturbing activity: ux V►��
Name � K o E-mail Address J—w - Gyww— G•
Tele hone CCtM
p �� Cell # ' � Fax #
7.
Landowner(s) of Record (attach accompanied page to list additional owners):
Ww&— cnal d 61 740 /JCOi
Name(s) Telephone
Current Mailing Address Current Street Address
TO 0 I qC G1 f CPf 5— c1
City State Zip City State
Fax or E-mail address
W.
8. Deed Book No. V 1 (6 A"I Page No. � � 734— Provide a copy of the most current deed.
Part B. �1 au
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide
&ehRive list of II respo sible rties on an attached sheet. Include requested information):
�i%ft�h�@ Rot he-"�
Name E-mail Address
Current
QMailing Address t
I,LIX/l(/IV 1 pV��
City I�] Mate Zip
Telephone l"1 _I u q�
Current Streit Address
City
Fax Number
State
r� t(�l-
Zip
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.
Ct 5VVN CIA -C 4a.— VrW
T pprinAnm ��vMe�( q� Title or Authority
'4 Nj Z)Z,l
re Date
11 La _�ri 7 � h A rztl,VL , a Notary Public of the County of p
State of North Carolina, hereby certify that 1,c, Scm ��« G� r1�� 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 _day of j'\A _jL 20 _
seal ' ��Tqq� a
y .
p�S c9 '3:'
12 .20"
.,.. C`
t
Notary
My commission expires_ Cl) t _