NCC231312_FRO Submitted_20230505

ICIPIIII 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
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 k. DA+,I 11. - c Z U "l�`' /k-\ie-►.ly E U A_R._J ele, ki e_
2. Location of land-disturbing activity: Jurisdiction GaA-R-4 E2- (Wake Co. or Municipality)
Highway/Street 14� Mt C.Kt E. Latitude 3 5, 7 o8 Longitude - 7b 6,2.4
3. Approximate date land-disturbing activity will commence: APeaI L 20 Z 3
4. Type of development(residential, commercial, industrial, institutional, etc.): f34,,tK (Co M .
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1Du 4%LI: / I.L y r,c , cT:: rr. }
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Eddie Gontram E-mail Address [e-mail]
Telephone [phone] Cell# 919-291-1789 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
KS F3A4K O1/ q- 773- 26SLa
Name(s) Telephone Fax or E-mail address
q20 -7--A AVE-AIL/6 120 7.- 4 ye/due
Current Mailing Address Current Street Address
G 4 Q ,ter - , xl Z 7 G•Z C a-A,/ .-^ , ..Lc_ a 7 S.-2q
City State Zip City State Zip
8. Deed Book No. /2t30 Page No. q ag - 5/iZ 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):
145$anlc, ( . Cu.)or m ks biu)t.+'AC. c. onn
Name E-mail Address
—PO Box tattl ION N. Q r is Inc k4-C 131v d .
Current Mai'ng Address Current Str t Address.)
Sr '"eta N G TM(1 5 1 ,da I.V. an
, rl
City `` (� pS�tate Zip City State Zip
Telephone �q``((��. `'1�0, 1041 Fax Number CM. Ck0. Z U g'

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:
KSKanIG, h G • -e oc k ® s bar>>L1 nG . C on
Name E-mail Addre s
cMseuzivill Nye h La. Qa0 sever ,Ave
urrent Mailing Address Current Street Address
r nor 0 C, a15aC1 Gamer w G -D.-Ste{•
City ((�� State Zip City State Zip
Telephone Ck'g•11.3.W4O Fax Number q to 1
`�"� 3 • Div'"�/�/ D"
(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:
&Y\V ,Shc • wof ," ICS lea h ;11 C• csmn
Name of Registered Agent E-mail Address
1X11(2(12.I 103 I I . 2,6 C3�hr1 lea() �Ivc�, .
Current Mailing Address Current Street Addres• s)
6 mi- -V-) I N G a-,sii �r�i-kke-P ld• NC a-)z;1 1
City (� State Zip City State Zip
(�
Telephone "1 q• R . - Q10 I Fax Number CI , `3Z• g.IQgt.I
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.
Earl W.Worley,Jr.
Pres dent/CEO
T •: ti r in n me Title or Authority
i1,ri�'' 3-zO-z3
Si. . ur: Date
•
I,))cnt c.t W• E-I'i b`1 , a Notary Public of the County of W 1 �40 h CO'1J\-kj
State of North Carolina, hereby certify that Ear 1 f or ,1'r, appeared
personally before me this day and being duly sworn acknowledged that thb above form was executed by him.
Witness my hand and notarial seal,this eli day of Or% , 20 a3
. 2(1,0 )
Denise W. Elliott ary
Seal Notary Public My commission expires "{ •ti , aoaLl.
Wilson County, North Carolina ,t
My Commission Expires q•I 402