NCC233325_FRO Submitted_20231128

11111.11 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
,. SEDIMENTATION POLLUTION CONTROL ACT
WAKE 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
Noloti( rtot.INA 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 tar 6 iilLS fate
2. Location of ( 1)/!`land-disturbingnn activity: Jurisdiction wt# e 6A (Wake Co. or Municipality)
Highway/StreetJU11 i////1 /l-Latitude 3J, l0 1 Longitude ` "`4.(3
3. Approximate date land-disturbing activity will commence: HI--2- Z-3
4. Type of development(residential, commercial, industrial, institutional, etc.): /6J/vE7 iV---
5. Total acrea a disturbed or uncovered (including off-site utilities and borrow/waste
areas): • *11
6. Person toc contactnt� should
/erosion
/and sediment control issues arise during land-disturbing/di activit/y':�/�
Name ✓��// E Ole ILV/ E-mail Address 5/�I1/Y0/ZN/I -516O // 5,��
Telephone Cl f-46 �''7 Soq Cell# Vas-- rug Fax# 'Y /�
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Name(s) Telephone Fax or E-mail address
q/ZU P-NsiN tiffiy s ff i 9/ j 6W6,'J be st
Current Mailing Address Current Street Address
ftit8611 V, zed l c Mill IL z7&c
City j '/�Sttate Zip City State Zip
8. Deed Book No O Q`7 Z Page No. O wV s" 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):
lioNSCAe a t/CDtc ILC 5II11N 4O050 ataikiS,eaf)
Name E-mail Address
ql z1 IJNJ6A/ why Irk zx qlu kJJIH AO sff icy
Current Mailing Address Current Street Address
CGu AK_ Z7!/r /l#!16H NC - 7�6/c-
Y State Zip City State Zip
Telephone q19-w-1�j)�� Fax Number f

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:
II IW5 6c 6W/S a NAfiVt l�'�P,�SiWe,(��1
Name of Registered Agent E-mail Address
q/i/ big AR '.feY 7(1) 411W i9EGAI 40 ik eh
Current Mailing Address Current Street Address
IWO AIL u4/1 atell-/ ke--- V4----
y State Zip City State Zip
Telephone q11q- 'gç- 1S4 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 inf rm ion provided herein.
Si/��/ /LV/ 0
Type or i t a Title or Authority
11-"Z-20 'i
Signa ure Date
I, •,_05 1.-W C\ �C,\ a Notary Public of the County of L/ W ,..._
State of North Carolina, hereby certify that S ks'.r\Q C) Gr ' t € appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
t
Witness my hand and notarial seal, this d day of Nee '' , 20 -3
% 0o• ••~'•' � fir+
:`�pl ARt- . ota y
Zeal sj
}, 1 V My co mission expires ( 7 )--C/
w i"f •'• „..o`er ,.