NCC230168_FRO Submitted_20230120

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
' r No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
IM
County Unified Development Ordinance before this form and an acceptable erosion and W7d
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NOIM' 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 Myers Residence
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 2137 Rolling Rock Road Latitude 35.958 Longitude -78.572
3. Approximate date land -disturbing activity will commence: December 15, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): single family residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.63 acre
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Adam Marlow E-mail Address adamm(@ruftv.com
VA
Telephone Cell # 919 616 2392 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Glen & Cynthia Myers
Name(s)
14905 Celle Way
Current Mailing Address
Naples FL 34110
City State
8 Deed Book No. 19007
Telephone
12257 Beestone Lane
Current Street Address
Raleigh, NC 27614
Zip City
Page No. 2289
State
Fax or E-mail address
Zip
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):
Glen & Cynthis Myers [e-mail]
Name
12257 Beestone Lane
E-mail Address
12257 Beestone Lane
Current Mailing Address Current Street Address
Raleigh NC 27614 Raleigh NC 27614
City State
Telephone [phone]
Zip City State Zip
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 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 Addr88s
Current Street Address
State Zip City
Fax Number
Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, atiarh a eepy Of the Certtfitarte 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 Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number
The above in€ormatian 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.
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Owner
Title or Authority
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1, _. Ct U h'1 �+� a NotaryPublic of the County of 0.1-+_
State of North Carolina, hereby certify that &Y1 ii�) . & a- 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 _I day of 20
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