NCC233229_FRO Submitted_20231030

"WI 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 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 Cornelius Perry Residence
2. Location of land-disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street 2132 Chalk Road Latitude -78.467 Longitude 35.940
3. Approximate date land-disturbing activity will commence: October, 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Single Family Residence
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.83 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Cornelius Perry E-mail Address capps810aatt.net
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Cornelius Perry [phone] capps810Aatt.net
Name(s) Telephone Fax or E-mail address
PO Box 61416 4129 Bay Rum Lane
Current Mailing Address Current Street Address
Raleigh, Raleigh, N.C. 27610
City State Zip City State Zip
8, Deed Book No. 018149 Page No, 00296 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):
Same as above
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
N/A
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:
N/A
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.
Cornelius Perry Owner
Ty or print name Title or Authority
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Signature 7 7/c)?—,
Date
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ra� E. � a C , a Notary Public of the County ofWAY.11 r1
State of North Carolina, hereby certify that ( mJii 'rr„t appeared
personally before me this day and being duly sworn acknowledged that the abo a form was executed by him.
Witness my hapaygn�{{ notarial seal, this 1 dayof r ;
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4� Notary �/ !V.
Seal ;
I'so rcommission expires CO3 /2O27
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