NCC231384_FRO Submitted_20230510

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
i Det d bibo
COUNTY sedimentationCountyUnif ed control planvelopmen haveOr been completedinance efore and th s approvedform byand an Wake Countyaccepta le Departmenter sion ofand
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 Boulder Creek Ln Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Boulder Creek Ln Latitude 35.95038 Longitude-78.71377
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):7.39 acres
6 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeff Ammons E-mail [e-mail]
Telephone [phone] Cell# Same Fax# N/A
7 Landowner(s) of Record (attach accompanied page to list additional owners)
Ammons Const Co Inc. 919.427.2322 [e-mail]
Name(s) Telephone Fax or E-mail address
7200-101 ACC Blvd Same
Current Mailing Address Current Street Address
Raleigh NC 27617
City State Zip City State Zip
8. Deed Book No 1966 Page No 508 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):
Ammons Const Co Inc. [e-mail]
Name E-mail Address
7200-101 ACC Blvd Same
Current Mailing Address Current Street Address
Raleigh NC 27617 Same
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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 Stale 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.
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Type or print name Title or Authority
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Sigrt�ture Date
I, lexesa_ Csr. CIO W e.rs a Notary Public of the County of
State of North Carolina, hereby certify that _ ,ft4f' Min rr.on5 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 3 rd day of tJ m/ember 20 as
SSA :CLcSWI�RS� 7Z/.(- —' (1!- '1-�L�
NOTARY PUBLIC Notary
WAKE COUP.'TY �^
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