NCC231998_FRO Submitted_20230629

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. I 0 1
1. Project Name LJ1 .)Ctic� 7(d g,e
2. Location of land-disturbing activity: Jurisdiction �`vt1K (O
L.)h}- ` (Wake Co. or Municipality)
Highway/Street Li l) (AV(tn%h C s4- Latitude
357 l`"}q/ Longitude' -/ .65tief
3. Approximate date land-disturbing activity will commence: I Z- - ( - 2 0 ZZ
4. Type of development(residential, commercial, industrial, institutional, etc.): 'PSi -1-1
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 5-fav h kC(•11 b E-mail Address S�eueh g IC T
� c� I J Giri`-�t'UC��'lf�i� i 4 t✓ .COvh
Telephone Cell* i (q• �l ZZ-ki Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
ut -�GS��vwS 13Ma 1ti )Pi Ico( Pehalote- 5Oj--(`1U• 70`18
Name(s) Telephone
Fax or E-mail address
fiata 1'6 DgA_k
Current Mailing Address Current Street Address
City State Zip City
State Zip
8. Deed Book No. I a (60 Page No. 2.1 l0 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):
I�7 C6,t5ScYUL'Ich I1nG
Name Ue
In IGTCOt yuC4 ion tHC . Co"At
E-mail Address
Current Mailing Address Current Street Address
City
State Zip City State
Zip
Telephone I - S(0j 1 Fax Number N/J1

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.Prz",j
e1(6 diefTh
Type or print name le or Authority
I 2_7
Signature ..__--- Date
I, ` VUICa r ►► 5 I'11(- , a Notary Public of the Countyof
� W l�r�
State of North Carolina, hereby certify that S1-Q.UQr� ` �o L� appeared
eared
personally before me this day and being duly sworn acknowledged at the ate form was executed by him.
Witness my hand and notarial seal, this 1 day of NCAJA-KbeY 20�-�—
VIAJUAki(-1, -W\A-Ay4/k
Veronica M.Saghir Notary
Seal NOTARY PUBLIC
Wake County,NC MY Commission Expires 8-25-2027. My commission expires 0 ))�-f 2c%Z-/r7