NCC233469_FRO Submitted_20231122

WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
7WAKE No 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.
LOT 61 OF GRAND HIGHI ANDS ESTATFS
1. Project Name
2. Location of land-disturbing activity: Jurisdiction U\IAKE (Wake Co.or Municipality)
Highway/Street I GA( Y 1.6)(11_ Latitude 35.901700 Longitude -78.494590
3. Approximate date land-disturbing activity will commence: September 20, 2023
4. Type of development(residential,commercial,industrial,institutional,etc.): RESIDEN I IAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_ 0.65 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name VAIBHAV LAIN E-mail Address VJ@'SHAILHOMES.COM
Telephone Cell# 919-633-0681 Fax# [phone]
7. Landowner(s)of Record(attach accompanied page to list additional owners)
SHAH CONSTRUCTION 919-728-4801
Name(s) Telephone Fax or E-mail address
2841 PLAZA PLACE 2841 PLAZA PLACE
Current Mailing Address Current Street Address
RALEIGH NC 27612 RALEIGH NC 27612
City State Zip City State Zip
8. Deed Book No. M Page No. 2320-2022 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):
SHAIL CONSTRUCTION LLC JAINM( SHAILCONSTRUCTION.COM
Name E-mail Address
VAIBHAV JAIN 114 1 EALIGH I- LANE
Current Mailing Address Current Street Address
(,Af.'y NC 27513 CARY NC 27513
City State Zip City State Zip
919-633-0681 Fax Number 919-882-9077
Telephone

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
1 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.
VAIRHAV LAIN MANAGING MEMBER
Type name Title or Authority
f/23/23
Si nature Date
9
I, K c fe Es m e ra lf1a fIlvareia Notary Public of the County of )Qh n S to n
State of North Carolina, hereby certify that VOt I b h nt v To I 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 �3r day of 191/t i LA St ,20 93
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