NCC231682_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 [phone]asa 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