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HomeMy WebLinkAboutNCC231682_FRO Submitted_20230606 Will WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT W1`11�G 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 NORTH CAROL(NA 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 Lpoi ER 1066- ).s IA fE5 2. Location of land-disturbing activity: Jurisdiction WIN Kr (Wake Co. or Municipality) Highway/Street i tl c rTC2 012/v6. Latitude 35''731.43 AI" Longitude 7 0.4 0 14 y,PI!' 3. Approximate date land-disturbing activity will commence: 0Vot/Z0Z3 4. Type of development(residential, commercial, industrial, institutional, etc.): RESIDE-A-Pr/A - 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): F1',Z 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name dot{I.) 1-EC - E-mail Address S1EE(..sp c.-Y41400.c.0" Telephone 911-711-1asa Cell# Fax# c i 1-1-11 -/G 6/ 7. Landowner(s)of Record (attach accompanied page to list additional owners): (3 f P'\ «vEsTr'Eu T G col PA' 919-481-9000 colinmacnair.com Name(s) Telephone Fax or E-mail address I13S KlLDP(12E FARr''l RD, Current Mailing Address Current Street Address C-ARY Nz- 27C// City State Zip City State Zip 8. Deed Book No. I F3+1 I Page No. 11.3 4 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): id 1\ —(Y1e. Li C Meiscn g ii(k In (Oro Name E-mail Address Current Mailing Address Current Street Address City I Q cl� �6 '"�gState cy Zip City State Zip Telephone Cif " " 627 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: are Q.�4 SACLA4x1 It1POc r t , Co Nam- of Registered E-mail Address Current Mailing Address Current Street Address City State ` SC 27�/J C Zip City State Zip �te� � D,4.Nomb rJ l�c�r.T 4f 1 t�et 54�lld Telephone O U����5-- ��7 Fier 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 RprD ELS ca ) 1✓SS St1N P e Type or print name Title or Authority Signature 'S i I I Z i )ati Date i, (mil i r1 t pta I , a Notary Public of the County of o e. State of North Carolina, hereby i ere y certify that �C� �-I 5())'1 appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. lh Witness my hand and notarial seal, this o � day of ,t47\1,eober , 20 a 444 Nota f.i. Seal My commission expires F -Y" '7 202 C -49 Celinda Howell NOTARY PUBLIC Wake County North Carolina My Commission Expires December 27,2026