NCC233437_FRO Submitted_20231120

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
.• SEDIMENTATION POLLUTION CONTROL ACT
WADENo 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
NOR I„CA,t<,,,NA
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 Sauls Landing Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Moss Rd Latitude 35.791769 78.332437
Longitude_'
3. Approximate date land-disturbing activity will commence: 4-30-23
4. Type of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 4.75
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Harold A. Yelle II E-mail Address aveseraleigh.twcbc.com
Telephone 919'877'9992 Cell# 919-971-8185 Fax# na
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KEVIN H. ROSEN
Name(s) Telephone Fax or E-mail address
2504 WHISTLING QUAIL RUN 2504 WHISTLING QUAIL RUN
Current Mailing Address Current Street Address
APEX NC 27502-8419 APEX NC 27502-8419
City State Zip City State Zip
8. Deed Book No. 18495 Page No. 1902 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):
Sauls Landing, LLC [e-mail]
Name E-mail Address
200 Sanford Rd 200 Sanford Rd
Current Mailing Address Current Street Address
Pittsboro NC 27312 Pittsboro NC 27312
City State Zip City State Zip
Telephone [phone] 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:
Harold A. Yelle II aves(a�raleigh.twcbc.com
Name E-mail Address
7700 Serenity Lake Dr 7700 Serenity Lake Dr
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State Zip City• State Zip
Telephone [phone] 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:
Steve Fitzpatrick Managing Partner
[e-mail]
Name of Registered Agent E-mail Address
200 Sanford Rd 200 Sanford Rd
Current Mailing Address Current Street Address
Pittsboro NC 27312 Pittsboro NC 27312
City State Zip City State Zip
Telephone [phone] 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.
Steve Fitzpatrick Managing Partner
Tye ame Title or Authority
) 41q-'
'gnats Date
I, A51 P , a Notary Public of the County of ' 4
State of North Carolina, hereby certify that cf4v-- �Ai. 44(.41 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 11 day of li( , 20 -S
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