NCC230968_FRO Submitted_20230405

Will WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
. SEDIMENTATION POLLUTION CONTROL ACT
7NoS person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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County Unified Development Ordinance before this form and an acceptable erosion and
NTYsedimentation control plan have been 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 N/A in the blank.)
Part A.
1. Project Name 7? �GX1cre40 Z'5 Vc
2. Location of land-disturbing activity: Jurisdiction LDc.& CD (Wake Co. or Municipality)
Highway/Street Ailtfbury lep Latitude ,35193 -go Longitude - 78.S V5'a4
3. Approximate date land-disturbing activity will commence: Mora_ I 2DZ3
4. Type of development (residential commercial, industrial, institutional, etc.): rcSie4..-40/4--C
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): O. 8 S-
6. Person to contact should/erosion and sediment control issues arise during land-disturbing activity:
Name 7k //lPrti f E-mail Address hOtPeeil r' iti/ficirrrt. (o►s,
Telephone Cell # q/q 3s/,f- tS/y Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
-J arias E 41/,.- G� 9/1-,3ys=os/
Name(s) p a. 13c)x gellef a Ira j Telephone Fax or E-mail address
CD 14/f apet,s ecoi.sf. 21< q/8 ,¢/o. , G/-
urrent Mailing Address Current Street Addre s
,ici AUL 2 76LY .24,-4,yi- /vG_ .76/.f"-
City State Zip City State Zip
8. Deed Book No. ZOIL Page No. /Q/Z- /9,9 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):
J'YlvrU3 C h/kw/ s a 12 jrxor;s. es rag-,_
Name E-mail Address
D. -Dtv.c ort ! 9/i 4i607 �—�-
Current Mailing Address Current Street Address /
�•LDec'6L is ,-7jZ < 2— Ne-
, - o?7G/f
City State Zip( City State Zip
Telephone Fax 3y-S:-D37y 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 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
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
//--r lberf 3 C yt• -r-M /4•4L i4,rr 15 ?at-A',
Type or rint nam Title or Authority
t Z-/o -217
Signatur Date
I, 041ctl [IL--Pc ka AAA, , a Notary Public of the County of (,{../61e.,2
State of North Carolina, hereby certify that I-IC.4'.{ ni JVIriS appeared
personally before me this day and being duly sworn acknno'wldiged that the above form was executed by him.
Witness my hand and notarial seal, this iv— day of oe-ltti-(,6LLvt, , 20e2.a_a1 cii(-a-ptd-uie..,'
s.o MARY ELLEN POTANOVIC
;,= Notary Public, North Carolina Notary
Ti.� -al Wake County
u,i7 k:' My Commission Expires
Janet 5;2e29 My commission expires -411- l5--- Z_____