NCC230926_FRO Submitted_20230404

WWI WAKE COUNTY FINANCIAL RESPONSIBILITYIOVVNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Y V1`11� 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
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORT tI CA ROLINA 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 1_(i} 5-7 k.O?c-�j(d Pe..c /ve
2. Location of land-disturbing activity: Jurisdiction VU4k C-0 , (Wake Co. or Municipality)
Highway/Street'\3 a (/J6,4es Lak.Latitude ;5.er1 .337g Longitude -.7g,ssu-r-74„,
3. Approximate date land-disturbing activity will commence: F . 15' aba.3
4. Type of development(residential, commercial, industrial, institutional, etc.): Pe9Le dy p
5. Total acreaae disturbed or uncovered (including off-site utilities and borrow/waste
areas): , 1-/5-
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name `j,a/n.t n IC . i&)e- rEf E-mail Address C2 A p fIy.p Ej' -cD11
LC oil
Telephone((C(-f(6,'R,--6 7S Cell# Fax# qc --y(p a- g/(6x)
7. Landowner(s) of Record (attach accompanied page to list additional owners):
t eiaL �nSlyiz ib Lnr, 111'-1-(tea-07 7s gte3-1(Z,Q 1-f'b0
Name(s) Telephone Fax or E-mail address
Current Mailing Addressr Current Street Address
1kr1 /a C QT2S 3
City / State Zip City State Zip
8. Deed Book No. I'7cR )t,-, Page No.) LiR i1/"(0 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):
Name E-mail Ad ress
Current Mailing Addregs Current Street Address
gi
.,,-, 1r �?7S�
y / State Zip City State Zip
Telephone q1e,- 6j . --r- 7 Fax Number C71q - (-/&-,a -(71-M(,O

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 E-mail Address
Current Mailing 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
D 1 >((i )A b( f c?c 7 11"-e
Current Mailing Address Current Street Address
3 <J A)C_
City / �- State Zip City State Zip
Telephone q( 7I 7C Fax Number CT((ak 1-4(o — YL1(0rli
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.
� � : lrC 3rz—s ,
Type or print name Title or Authority
.LEA 3
Signature Date
I, Vick is yach> , a Notary Public of the County of \A/a k
State of North Carolina, hereby certify that ---be r � appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hanpnd-notarial,seal, this 241 day of , 20 Z3
A.°4., a: .41,5 fit
♦it ' '; y
Notary
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My commission expires 5 f 23/24,
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