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HomeMy WebLinkAboutNCC232900_FRO Submitted_20230927 ICP.11 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 Countyseimentati Unified Development O be b COUNTY don control plan have beenrdinance completedefor and this approvedform byand Wan ake Countyaccepta le Departmenterosion ofand NORTH CAROI.INA 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 Willow Landing Lot 54 2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality) Highway/Street 1609 Willow Landing Way Latitude -78.694 Longitude 35.579 3. Approximate date land-disturbing activity will commence: 9/22/2023 4. Type of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 0.737 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Jimmy Gaskins E-mail Address jagaskins@kbhome.com Telephone 919-768-7988 Cell# 919-868-5391 Fax# N/A 7. Landowner(s)of Record (attach accompanied page to list additional owners): KB Home Raleigh-Durham, Inc. 919-768-7988 N/A Name(s) Telephone Fax or E-mail address 4506 S. Miami Blvd., Ste. 100 Same Current Mailing Address Current Street Address Durham NC 27703 City State Zip City State Zip 8. Deed Book No. 019437 Page No. 01385 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): KB Home Raleigh-Durham, Inc. jagaskins@kbhome.com Name E-mail Address 4506 S. Miami Blvd., Ste. 100 Same Current Mailing Address Current Street Address Durham NC 27703 City State Zip City State Zip Telephone 919-768-7988 Fax Number N/A 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: Doug Schwartz dschwartz@kbhome.com Name E-mail Address 1405 Willow Landing Way Same Current Mailing Address Current Street Address Willow Spring NC 27592 City State Zip City State Zip Telephone 919-768-7988 Fax Number N/A (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: Corporation Service Company compliancemail@cscglobal.com Name of Registered Agent E-mail Address 2626 Glenwood Avenue, Ste. 550 Same Current Mailing Address Current Street Address Raleigh NC 27608 City State Zip City State Zip Telephone 800-927-9800 Fax Number Account#: 7227849 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. Doug Schwartz Division President, KB Home Raleigh-Durham, Inc. Type or print name Title or Authority Signature ° Date I, , a Notary Public of the County of (\pc, r. State of North Carolina, hereby certify that Sc ..>c u c\Z appeared personally before me this day and being duly sworn acknowlddged that the above form was executed by him. Witness my hand and notarial seal, this a U� 'day of �e,0,e `cam , 20`)S ERIN N POLLOCK �\ NOTARY PUBLIC b1 ri _, Johnston County �J 1 lxhoCKl, North Carolina Notary Sea My Commission Expires June 17,2024 My commission expires �v.2, \1 0c3A