NCC230407_FRO Submitted_20230214

35-W
�0; �Pp 0 - �_
WAKE
COUNTY
NORTH CAROL INA
Part A.
WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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
sedimentation control plan have boon 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 NIA in the blank.)
Project Name
.J
2. Location of land -disturbing acti ity: Jurisdiction �� � (Wake Co. or Municipality)
Hi hwa IStreot 710 m-latitude � , S -] Q Longitude ~ � 14`i J
g Y S' ���. g � r}-
3. Approximate date land -disturbing activity will commence: 'Va0 0 CC X
4. Type of development (residential, commercial, industrial, institutional, etc.): fkS)0�
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): , <L 03
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name to (-0,4- Ode _ E-mail Addressf aoloQ fl a d a''Sho "Us .y)k
Telephone Cell # (� 19, b bJ , q g-U Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�sY1 LA Q?a-�uu -R��
Name(s) Telephone
-S-5 ,91 S x �-ork_s"�d, , � M_Q_
urrent Mailing Address Current Street Address
ti- � � I SSig ►')'I-�
City State Zip City State
Fax or E-mail address
Zip
8. Deed Book No. r 90 I Page No. 6 -7 � 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
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Name F mail Address
Current Mailing Address Current Street Address
City Q State Zip City State Zip
Telephone `I I q "$ q q" "f W&6 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
E-mail 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 Numbe
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 Financialiy Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
_btV,S o(1�rs, Q
Type or print naOne Title or Authority
Sig re Date
---------'-,-,--n--------------------------------------------------------------------------------------II--__--,,-----------------------------
J
—Ta, I I'- I ZS , a Notary Public of the County of
State of North Carolina, hereby certify that _ ( rt/I appeared
personally before me this day and being duly sworn acknowledged ilhat the above form was executed by him.
Witness my hand and notarial seal, this 16D1hday
THERESA A.TREFFTZS
Notary Public
WaO ty, North Carolina
My Commission Expires
March 6, 2024
wwwwo
My commission expires