NCC233772_FRO Submitted_20231221

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
_=-: SEDIMENTATION POLLUTION CONTROL ACT
r 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
N(1 R1H CAItoLll.'A Environmental Services, Water Quality Division. (Please type or print and, if the question is not
1 applicable, place N/A in the blank.)
Part A.
1. Project Name u-6-1 1.-- � Arnold t L.-
I
TA
2. Location of land-disturbing activity: Jurisdiction 0 alf('e- `D (Wake Co. or Municipality)
Highway/Street IGiHn mil` Latitude 5L.633563 Longitude -::75- 5-296$ 7
3. Approximate date land-disturbing activity will commence: D` I-�' (-34)" 3
4. Type of development(residential, commercial, industrial, institutional, etc.): ‘ rS i'Uul.!Jt 1
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .49 , ,
6. Person to contact should erosion and sediment control issues arise during land-disturbinactivity
Name ( YTY g?MI(/� E-mail Address (Argot/lent-1ga wl ri ,mGS•Gd WI
Telephone q 16 Q0 —711 iV Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
L,f, . 1torU/\ I I q .A I C A Le, -)"lntll'Ceivl
Name(s) 11
Telephone Fax or E-m' it address
Current Mailing Address Current Street Address
kitA V,C_- i' /v C D-? 7
City /; State Zip City State Zip
8. Deed Book No. 51 '7( Page No. (J a-07 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 I
&I r.ennnsible parties on an attached s eet. Include requested information):
d\A&IdMiln
Name t r E-mail Address
40 0 q 4- /("-Ve
Current Mailing Address Current Street Address
tliaK; d- 44 g‹ 7
City State Zip City State Zip
Telephone i q k 3g.:K 7 Fax Number
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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 4P rty is a Corpor tion, give name and street address of the R gistered Agent:
k Oil (4 Oc(, �f O►1Ci►'YI 14W+r l' '1'(
Na e of Registered Art
E-mail Address
j
q 6 1 (VA 1-1-I
Current,Mailing Address Current Street Address
Uct I
S-1— A 1(- d-07
City // State Zip City State Zip
Telephone //y6s5ger 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. t
01 04g,i101,1/411 vi
Type or pri name Title or Au on
_ -7},Li__a:3
Signature Dat
I, ( N,.tbL 6-41 C* i/ , a Notary Public of the County of •fOnrll,n
State of North Carolina, hereby certify that ,(Y & (34,ldw►v--,
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 •y day of -u fl , 20 2.7
Notary
Se-1I
P. NICOLE RAY CADDELL My commission expires (Ylav [/ 020-7 y
NOTARY PUBLIC
Franklin County
North Carolina
My Commission Expires $' /0624
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