NCC231550_FRO Submitted_20230522

MP" 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
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
��,. �� ,,�14r1 Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. , P
1. Project Name �.-o 1 1 pl fC-SCOtt M.(.20 &
2. Location of land-disturbing activity: Jurisdiction `/3C x CO • (6ke Co or Municipality)
5301—1 Highway/Street tr•JoodC•ti ASS LJ atitude.3L, .Q0O t l Longitude—fig • %A0Co( o Lcrl
3. Approximate date land-disturbing activity will commence: M, c�) 0'a 3 /�
4. Type of development(residential, commercial, industrial, institutional, etc.): ILe S; ci7E-t C
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): y SO
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name (...a bbi 1 xt5oC�. E-mail Address o� C..; 5c "`�m
p, � GCY"l
Telephone '119 •(.aDt-4- -a04 Cell# 9 i 9 ( )i4Fa
.
-F ' x# ( , c6=-70 . 7l�14-
7. Landowner(s)of Record (attach accompanied page to list additional owners):
c� sc-V k B. ass, LoL - 919 .Lkiu .c600 LI00L G>> f- c
Name( ) Telephone Fax or ail addre c
s
tA'Y'")
0,0 . 6'0`t, 9 S'9 2 (D 5 1 B a.r-‘ . 8. r c :.:� 0 0
Current Mailing Address Current Street Address j
City State Zip City State Zip
8. Deed Book No. IS 33 Page No. D S 3 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):
C1‘ea Sc �L): `d eAS, , IXIC • ri,s c . c. �`'-- -Li_ s c_c--e. rv>_j . cavl
Nam E-mail Address t
P.o. Boy 9gcl aL S°3.� d d AiriLd, Swth, 001
Current Mailing Address Current Street Address
City `15:h 0 State -/ Zip aik.L,5 t l a State / `
CityjZip
� Cr/Telephone 91 • 7(.0 - 303 Fax Number i 9, S 70 • /0 9 '4

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 I C k aik,.! 6,zitefrt- Pte61 )e vil-
Type or print name Title or Authority
Viti23
Si nature Date
I, 004 /14- Sof , a Notary Public of the County of (Like
State of North Carolina, hereby certify that (clear J. IJq,r. dri appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
o by him.
AA
Witness my hand and notarial seal, this 16 day of tarj , 20 ,25
(9YLn1 .- )4e
oVIDA MSgi Notary
Notary Public-North Carolina i /�
Wake County My commission expires ( °)
My Commission Expires Apr 30, 2027