NCC232998_FRO Submitted_20231005

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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
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 Lot 71 Falls Reserve
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co.or Municipality)
1601 Rock Dove Way
Highway/Street Raleigh, NC 27614 Latitude 35.983920 Longitude -78.666520
3. Approximate date land-disturbing activity will commence: Oct. 9, 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): .80 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Libby Hartsock E-mail Address Libby.Cityscapeqmail.com
Telephone [phone] Cell# 919.624.8204 Fax# [phone]
7. Landowner(s)of Record (attach accompanied page to list additional owners):
CityScape Builders, inc. 919.676.8008 919.870.7094
Name(s) Telephone Fax or E-mail address
PO Box 98926 8321 Bandford Way; Suite 007
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No. 16678 Page No. 0790 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):
CityScape, Builders, Inc [e-mail]
Name E-mail Address
PO Box 98926 8321 Bandford Way; Suite 007
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number 919.870.7094

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A 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:
Richard J. Barrett [e-mail]
Name of Registered Agent E-mail Address
PO Box 98926 8321 Bandford Way; Suite 007
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number 919.870.7094
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.
ype or print name Title or Authority
i'-'-( 1 tpnV2o /0 / 3 i
Signature Date
I, "©)c2, Cv vZ , a Notary Public of the County of roc c
State of North Carolina, hereby certify that rQ Howl, '�. c,.vvc-4+ 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 3" day of ©c.-+- , 2023
JOSE CRUZ Nota
Se Notary Public
ake Co.,North Carolina My commission expires c %{27t2
My Commission Expires Aug.27,2028