NCC233534_FRO Submitted_20231130

113Pil WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
r11(im-111
7 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
OUNTY sedimentation control plan have been completed and approved by Wake County Department of
(ANULIhA 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 5325 BENT LEAF - AMATO
WAKE
2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street BENT LEAF Latitude 35.698 -78-703
Longitude
3. Approximate date land-disturbing activity will commence: OCTOBER 30, 2023
4. Type of development (residential, commercial, industrial, institutional, etc.):
RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1 .4049587 (61 ,200 SQ FEET)
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
RICHARD GEPHART [e-mail]
Name E-mail Address
Telephone [phone] Cell # 919369-4466 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
MICHAEL AND DEBRA AMATO 925-580-9382 [e-mail]
Name(s) Telephone Fax or E-mail address
1383 CLAVEY RIVER CT 1383 CLAVEY RIVER CT
Current Mailing Address Current Street Address
LIVERMORE CA 94550-8521 LIVERMORE CA 94550-8521
City State Zip City State Zip
016798 01801849
8. Deed Book No. Page No. 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):
GEPHART BUILDING COMPANY, LLC [e-mail]
Name E-mail Address
4016 Barrett Drive - Suite 201 4016 Barrett Drive - Suite 201
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
919-369-4466
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:
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
Pgg pA gro t giy n r� �St[9et LL address of the Registered Agent:
RICHARD GEPHART U IVY [e-mail]
Name of Registered Agent E-mail Address
4016 Barrett Drive - Suite 201 4016 Barrett Drive - Suite 201
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
919-369-4466
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 1
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.
RICHARD GEPHART MANAGER
Typer print name Title or Authority I
P
7C7t
/ o — /) - 3 f
ignature Date 1
I, 4) /;b /`( ) , a Notary Public of the County of L4...(1 (4 e_ j
Carolina, herebycertifythat P �u�C/ /� -Uri KL� G C it au / appeared I
State of North G �
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 L, day of ajdOt.°vv .' , 20 a 3
JAWWAD TAALIB EVANS 47.....----
NO. t 'Y PUBLIC
Noat ry
va he County My commission expires / . / Z/41 6
North Carolina
My Commission Expires Dec. 28, 2026
1
1
II
i
. 1 , - • - . , . ry