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HomeMy WebLinkAboutNCC232369_FRO Submitted_20230808 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 i Dot be an COUNTY sedimentationCountyUnif ed controlevel planpmen haveOrdinance been completedefor and this approvedform byand an Wakeaccept County le Departerosionment ofand N(1RIH 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 Norwood Park Subdivision 2. Location of land-disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality) Highway/Street Mt Vernon Church Rd Latitude 35.943286 Longitude -78.671846 3. Approximate date land-disturbing activity will commence: August 2023 4. Type of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 3.37 acres 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Kevin Mangum E-mail Address kevin@mangumdesignbuild.com Telephone 919-422-2126 Cell# 919-422-2126 Fax# 7. Landowner(s)of Record (attach accompanied page to list additional owners): NGI Investments LLC Name(s) Telephone Fax or E-mail address PO BOX 91327 Raleigh NC, 27675 0 Norwood Road Current Mailing Address Current Street Address Raleigh N.C. 27614 City State Zip City State Zip 8. Deed Book No.18883 Page No. 764 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): Mangum Design Build kevin@mangumdesignbuild.com Name E-mail Address 6701 Mt. Herman Rd. Current Mailing Address Current Street Address Morrisville NC 27560 City State Zip City State Zip Telephone 919-422-2126 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. Kevin gum / ''NAffit- Type print name Title or Authority Zki7073 Si re Date I, S\-e-.@\n .\\ , a Notary Public of the County of \NN,0.‘L9— State of North Carolina, hereby certify that �Q,�:��� � `N� 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 1 day of Vc� V , 20 Notary Seal My commission expires Qom.\ �a�a S PHANIE 5 HARRIS Notary,��Public MMWaky County, m�misslion Edna AO 08,2026