NCC231478_FRO Submitted_20230516

"WI 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 sed(mentation control plan have been completed and approved by Wake County,Department of •
N:,wI., IN., 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 FIASENTREE PHASE ISF.LOT 542
2. Location of land-disturbing activity Jurisdiction WAKE COUNTY (Wake Co.or Municipality)
Highway/Street SANDYBROOK LANL Latitude N036 00'17 61^ Longitude W078`35 56 4i"
3. Approximate date land-disturbing activity will commence: 05 01 2023
4. Type of development(residential, commercial, industrial, institutional, etc) RE SIDE N 11�L
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0 50 ACRES
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ADAM SPE IRAN E-mail Address ASPL IRAN a M1'NOC)i_OM
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners).
ADAM SPEIRAN 919-868-5351 [e-mail]
Name(s) Telephone Fax or E-mail address
1005 KEITH ROAD 1005 KEITH ROAD
Current Mailing Address Current Street Address
WAKE FOREST NC 27587 WAKE FORLSI NC 27587
City State Zip City State Zip
8. Deed Book No. 019103 _Page No. 00919 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):
ADAM SPEIRAN ASPEIRAN a MI'NGO COM
Name E-mail Address
1005 KEITH ROAD 1005 KEITH ROAD
Current Mailing Address Current Street Address
WAKE FOREST NC 27587 WAKE FOREST NC 27587
City State Zip City State Zip
Telephone 919"68-' 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.
�ot-,nn 5�e i roar, rtsg—
Type or print name Title or Authority
Signature Date
I, $ l .virler trine r )L , a Notary Public of the County of W'4i ik r,
State of North Carolina, hereby certify that Ackar" 5 4(tL.JC', 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 � -- day of Apr.%1 , 20 a3
,;- o, KATHERINE CQNNER LUSKCa:14....,........„c7ruzej_
_:;116;. 7tary Public, North Carolina Not y
Franklin County
ny m1U 1O Expires My commission expires Le- 1(Q Q.(