NCC230769_FRO Submitted (5)_20230321

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
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
ti„ \ III t AIWI I N % Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Cambria - Section 1
2. Location of land -disturbing activity: Jurisdiction _ Wake County (Wake Co. or Municipality)
Highway/Street New Bethel Church Rd. Latitude 35.649711 Longitude-78.569104
3. Approximate date land -disturbing activity will commence: 01 2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 8.71 AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Raughley
E-mail Address [e-mail]
Telephone [phone] Cell # 919-795-9347 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Penny, Thomas H Heirs CIO David Penny Exec
Name(s)
Telephone Fax or E-mail address
5106 Overlook Drive
Same
Current Mailing Address
Current Street Address
Elm City NC 27822
Same
City State Zip
City State Zip
8. Deed Book No. 1493 Page No.
232 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):
Pulte Home Company, LLC
[e-mail]
Name
E-mail Address
1225 Crescent Green Drive Suite 250
1225 Crescent Green Drive Suite 250
Current Mailing Address
Current Street Address
Cary NC 27518
Cary NC 27518
City State Zip
City State Zip
Telephone [phone]
Fax Number NIA

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
Telephone Fax Num
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.
Chris Raughley
Type or print name
lam'
Signature
VP of Land Development
Title or Authority
1• t6.23
Date
I, M l/i i S 07 4PY1 a Notary Public of the County of I&C4 ;e C
State of North Carolina, hereby certify that Ia44h 14.1n appeared
personally before me this day and being duly sworn acknr#o owledged that the ab a rm s executed by him.
Witness my hand and notarial sea], this, e1 day of /1 V1 , 20-7e2--
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Seal =' �JAR yI,
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Notary
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