NCC233821_FRO Submitted_20231228

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
"� SEDIMENTATION POLLUTION CONTROL ACT
00.1111". 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.
Morgan Pointe, Lot 13
1. Project Name
2. Location of land-disturbing activity: Jurisdiction "gal`"' (Wake Co.or Municipality)
Highway/Street8405 Brady Pointe Latitude 5.19)`,L Longitude -78.737905
3. Approximate date land-disturbing activity will commence: `h " 202
4
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):0.50 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Hudson E-mail Address [e-mail]
Telephone N/A Cell# 252-218-0785 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
American Homesmith Triangle. L.L.C. 252-218-0785
ihudson(a�americanhomsmith.com
Name(s) Telephone Fax or E-mail address
3109 Quinn Drive 3109 Quinn Drive
Current Mailing Address Current Street Address
Wilson, NC 2789:i NC 27896
City State Zip City State Zip
8. Deed Book No. 10059 Page No. Ob '' 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):
American Homesmith Triangle. L.L.C. [e-mail]
Name E-mail Address
3109 Quinn Drive 3109 Quinn Drive
Current Mailing Address Current Street Address
Wilson NC 27896 Wilson NC 27896
City State Zip City State Zip
Telephone [phone] Fax Number NiA

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:
Joe L. Hudson. Sr. hudson6604©aol.com
Name E-mail Address
6604 Gravmoni Place E6604 Gravmoni Place
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number N%A
(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:
Joe Leslie Hudson, Jr [e-mail]
ariericanhomesmith.com
Name of Registered Agent E-mail Address
3109 Quinn Drive S1t 9 t7uinn Drive
Current Mailing Address Current Street Address
Wilson NC 27896 Vv'iison NC 27896
City State Zip City State Zip
252.218.0785 NA
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.
Joe Leslie Hudson. Jr. Men--it-iHt 1.iaiiacier
T p or print name Title or Authority
Si ,{04419
ature Date
I, 46/LL ,�Pi"k- � , a Notary Public of the County of / I i--G�"Z
State of North Carolina, hereby certify that OL L• tTL SF)-. r• appeared 3
personally before me this day and being duly sworn acknowledged that the above form kvas executed by him.
WitaesslraN land and notarial seal,this 1 q day of A"e ,20 5
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