NCC233562_FRO Submitted_20231201

110111 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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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
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 Le\ 4 1 Ir t n 1 A Y-CA—
J I
2. Location of land-disturbing activity: Jurisdiction \ ) ��� Cc.1 • (Wake Co. or Municipality)
1n I � i G n , � /
Highway/Street 1� 15,����"►)'}'c•�('� LatitudeaQ•O\5` I NI Longitude —1 U • U i.15 W
3. Approximate date land-disturbing activity will commence: Jan I i 2-L21+
4. Type of development(residential, commercial, industrial, institutional, etc.): V-eS 16 fif')11.0
5. Total acreaqe disturbed or uncovered (including off-site utilities and borrow/waste
areas): a 1\O Cn C4e$
6. Person to
contact should erosion and sediment control issues arise during land-disturbings activity:
f ./� V Name I ► tT t J-kf-CtiY O E-mail Address c 00 e r\n e c{i -CCM
Telephone CI kc\ 2 b VA UUt Cell# c�`C& v t< Fax# N 1 Yck-
7. Landowner(s)of Record (attach accompanied page to list additional owners): r ekryilti h Q
CON\h-ey-e, 0-e\/-e I o�o,m- 1� LL C' Ci `� 2 , 1 01 0'1 ch 11 - C Om
Name(s) Telephone Fax or E-ri4i1 address
Current Mailing Address Current Street Address
�/\ C \f- (-e - Nl C ?A 5C
City State Zip City State Zip
G
8. Deed Book No. 1 I 1 Page No. 2-(s( B 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):
.`� 0- 0 S�C'rjrAn(i CC�n� - -el��m�S �C��c�i -cum
Name Email Address
�'� n 1J ‘ S hue Y I/1 e C I� S'C�rvt
Current Mailing Address Current Street Address
City (A State �j Zip City , State Zip
Telephone C 1 _ 1 2?l- 1� O Fax Number lv�
0 C,n i-t-Civt 0 N-2 [upon cant LLC

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:
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.
D''‘,Cfck'ckno f,ec \sc.v-e 6-9 cyl
T,, o print name Title or'Authority
ign:ture Date
Ural MOh' , a Notary Public of the County of IJ
State of North Carolina, hereby certify that akt ' 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 ZI day of , 20 23
Mart
arol Public
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Notary Publlc l y(/(,1-l.� I� �'
Wake County
North Carolina otary
sea fly Cornmission Ex Ires 3/15/2028
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