NCC230287_FRO Submitted_20230131

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WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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SEDIMENTATION POLLUTION CONTROL ACT
WAKINo 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 { AROLINA 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__(-->-c,.d A,
2. Location of land -disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street�� / Latitude__ JVo7" LJTrg!�/�gMgitude
3. Approximate date land -disturbing activity will commence: Z j
4. Type of development (residential, commercial, industrial, institutional, etc.): ,
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):0_431)
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
41
Telephone SS3v019 Cell #
E-mail Address e4� 10600- r`�c " „/a•,,,G,�,,,,, ,`,�
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�:a rJc �rr L1 l4 - y l e-1 rPQ ' . , c e,,,,
Na�) Telephone Fax or E-mail address
3/o LJaq
Current Mailing Address
12QIa'cL. Alt c22L�[S
City State Zip
Current Street Address
City
M
State
Zip
8. Deed Book No. Page No. 1-7 y ,_ Provide a copy of the most current deed.
Part B.
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. I�n�cllude requested information):
15�6
Name E-rrfail Address
Current Mailing Address Current Street Address
20� �k 11 AIC I (Al S' I --
City State Zip City State Zip
Telephone_ Q11 -5,2 -01.° -7 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 A14/A
City State Zip
Telephone.
E-mail Address
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
E-mail Address
Current Mailing Address Current Street Address
IVIA
City
State
Zip City
Telephone 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.
Typer or print name Title or Authority
/- & - 2 3
Signatur Date
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►, 4 & 6P., ff/I (w r, , a Notary Public of the County of
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State of North Carolina, hereby certify that �y�/�'-�appeared
personally before me this day and being duly sworn acknowl dged that the above form was executed by him.
Witness my hand and notarial seal, this?`?= day of a / 20�_
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