NCC233330_FRO Submitted_20231108

r
_ WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
.�' y SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
[NORTH(AROIINA 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 65 Grand Highland Estates
Wake Co 2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
p y)
Highway/Street Grand Highland WaYatitude 36.026845 Longitude-78.592512
3. Approximate date land-disturbing activity will commence: 9/1/23
4. Type of development(residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.86
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Kerul E-mail Address [e-mail]
Telephone [phone] Cell# 770-286-1013 Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Braswell Custom Homes Inc 919-578-2945 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 40159 3908 Blackard Pond Rd
Current Mailing Address Current Street Address
27604
Raleigh NC 27629 Raleigh
NC
City State Zip City State Zip
8. Deed Book No.019254 Page No.00134 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):
Braswell Custom Homes Inc [e-mail]
Name E-mail Address
PO Box 40159 3908 Blackard Pond Rd
Current Mailing Address Current Street Address
Raleigh NC 27629 Raleigh NC 27604
City State Zip City State Zip
Telephone [phone] 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:
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:
t_ 5raS-_.d--1k cov e cv kob.f.5 6A.C. ,
Name of Registered Agent E-mail Address
PO dpx oiSr l y,og Pd„�
Current Mailing Address Current Street Address
ila►����. Nc. 7 767 fLk�5�. /lJL 2.76 0.4
City State Zip City - / State Zip
Telephone ��� - S 7g' ' l� '-4..5 Fax Number TWA
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.
Matthew Kerul Operations Manager- Braswell Custom Homes Inc
Type or print name Title or Authority
1/23/23
ature Date
I, N1Ca^ \� v� W\ , a Notary Public of the County of
State of North Carolina, hereby certify that N\C��'---►`K J\J\ 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 ) day of -)vtn\`,\c,. n , 20Vj
Ar,
Notary
!Seal
;`V My commission expires n U.1.>70 /c.= j,j,,
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