NCC233002_FRO Submitted_20231006

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W� No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County fine Dde be
COUNTY sedimentationUni ed control planevelopment haveOr beeninanc completedefor and this approved
form byand an Wake Countyacceptable Department ofand
NORTH Cauoi.wA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Lot 9 Creedmoor Manor
1. Project Name
2. Location of land-disturbingactivity: Jurisdiction Wake Co.
Y (Wake Co. or Municipality)
1209 Explorer Trail 35.992
Highway/Street Wake Forest NC 27587 Latitude Longitude -78.667
3. Approximate date land-disturbing activity will commence: 10/1/23
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.48
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
James Denton
Name E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Future Homes by Jim 919-363-4111 919-363-4044
Thompson,Inc.
Name(s) Telephone Fax or E-mail address
1105 Classic Rd 1105 Classic Rd
Current Mailing Address Current Street Address
Apex,NC 27539 Apex,NC 27539
City State Zip City State Zip
8. Deed Book No._ 019137 No._ 01957-01958 _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):
Future Homes by Jim [e-mail]
_ Thompson, Inc
Name E-mail Address
1105 Classic Rd 1105 Classic Rd
Current Mailing Address Current Street Address
Apex NC 27539 Apex NC 27539
City State Zip City State Zip
919-363-4111
Telephone Fax Number 919-363 4044

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.
James W Thompson President
Type or print name Title or Authority
-1� $•0. 2023
Signature Date
I, C� mberly 'Day I S , a Notary Public of the County of 114a.,t4v
State of North Carolina, hereby certify that Z,1 1 fYl ' 1'1Orni on appeared
personally before me this day and being duly sworn acknowledged that t above form was executed by him.
Witness my hand and notarial seal, this I'day of Al u.5+ , 20 2.3
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