NCC230785_FRO Submitted_20230322

I W. Ew WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
P=7 No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
AKICounty 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
AROI INA 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
McNeill Burbank Lots Phase 12 & 10B
2. Location of land -disturbing activity: Jurisdiction Town of Wendell (Wake Co. or Municipality)
Douglas Falls, Piney Falls Dr, Cardinal Perch Ln, Birdhaven Ln
Highway/Street Latitude 35 �7312g Longitude -7,9403290
3. Approximate date land -disturbing activity will commence: March 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): 3.191
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nolan Paussa [e-mail]
Name E-mail Address
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Nash Wendell Falls LLC 919-521-2583
Name(s) Telephone Fax or E-mail address
4020 Westchase Blvd, Suite 150, Raleigh NC 27607 same as mailing address
Current Mailing Address Current Street Address
E:3
City State Zip City
Deed Book No. BM2022 Page No.1930-1934
DB 015478 Pg 01623
Part B.
State
Zip
Provide a copy of the most current deed.
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):
CCH RDU LLC [e-mail]
Name E-mail Address
3739 National Drive Suite 128, Raleigh NC 27612
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
materC elating toCthe Wake e any notice,
Couprocess,
nty Erosion and ng I Sedimentation legal
contrrol proceeding
Ordinance arising
and/orof any
Land
matt g Y
Disturbance Permit:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
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
correc d information should there be any change in the information provided herein.
r CC'S P11 D,- 0f
T e or print name Title or Authority
- r)U
Signature
Date
LLtXA Po O L) , a Notary Public of the County of
v)� e-
State of North Carolina, hereby certify that ��' h o C , /D r / e r 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
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Notary
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