NCC233607_FRO Submitted_20231208

"WI 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
i Development c be io
COUNTY sedimentationCountyUnif ed controlv planlopmen haveOrdinan been completedeefor
and th s approvedform byand an Wake Countyacceptable Departmenter sion ofand
NORTH (.AROI N:, 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 Sidney Creek Phase 3
2. Location of land-disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street NC HWY 39 Latitude 35 . 811478 Longitude —7 8 . 2 6 8 7 9 9
3. Approximate date land-disturbing activity will commence: Fall 2022
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 56 . 15
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Fred Morin E-mail Address fmorin@drbgroup. com
Telephone 1 . 919 . 4 3 7 . 0 2 2 5 Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
DRB Group North Carolina, LLC
Name(s) Telephone Fax or E-mail address
3000 RDU Center Dr. Suite 202
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
8. Deed Book No. 17 910 Page No. 548 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):
DRB Group North Carolina, LLC fmorin@drbgroup . com
Name E-mail Address
3000 RDU Center Dr . Suite 202
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
Telephone 1 . 919 . 4 3 7 . 0 2 2 5 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
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.
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Type orri name Title or Authority
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S6(' Date
11-0.1V, � Lc nnq n , a Notary Public of the County ofCrionU 6I.
State of North Carolina, hereby certify that C,roa t 'I (n1 an appeared
personally before me this day and being duly sworn acknowledged th the above form was executed by him.
11
Witness my hand and notarial seal, this L day of , 20
O �,�a
•, '• % No ry
• NARY �'U ll,Sl o�lC
• My commission expires .
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