NCC240112_FRO Submitted_20240112

Ira 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
County D babo
COUNTY sedimentationUnified control planevelopment haveOrdinance been completedefore and this approved
form byand Wan ake Countyaccept le Department
er sion ofand
NOR H C AROl 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 AMPLIFY CHURCH EXPANSION
2. Location of land-disturbing activity: Jurisdiction WAKE (Wake Co. or Municipality)
Highway/Street 2884 NC HWY 42 Latitude 35-35' 27.75" N Longitude 78-41' 34.04" W
F J
3. Approximate date land-disturbing activity will commence: _, ,i kO,(
Q INISTITUTIONA
4. Type of development (residential, commercial, industrial, institutional, etc.): (CHURCH)
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.02
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Namela3tJf Ph\ \LA) 1 & I (.0 E-mail Address •y � E
Telephoneq,( i(1a-06�5 Cell # �y®— - - 5Fax# ►�9
7. Landowner(s)of Record (attach accompanied page to list additional owners):
\W U- Chu rcn cla- "� ,3-Do i �ulrclo�,
Name() Telephone Fax or -mail a dress
Current Mailing Address Current Street Address C141{19
Oa) OCAllkg s\kkAr\ij2 AkaA_LA,u
City ate Zip City ii State NI Zip
8. Deed Book No. (0 12 Q 43 Page No. i:J� 1� '" 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 responsibleAnoirl
parties on an attached sheet. Include requested information):
t11�. r 1 I\1 1.E p NkQ Ck t i ill CO, Q i-C;�\u ( 1.
Name L-mail Address
4W039 Ng_ I-0A 1.0_ 4a.ki aA \Mcu
Current Mailing Address Current Street Address itty_
‘atial
4V(1 0 OC cr 'Sq ' .110AAto ; (a.,chtty
ity State Zip ity State Zip
Telephone c lv . off" 0 15 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.
c)f\ vi\jk Cd-tv R51-
T e or pint name Title or Authority
Yp
esk
Signature Date
I, i ���� , � ( L S�� , a Notary Public of the County of l/OC,Lia
State of North Carolina, hereby certify that P ►t I ¶ ( ( appeared
personally before me this day and being duly sworn acknowledge that the above form� was executed by him.
Witness rrat�lVfcf4l0 vial seal, this (N61 day of K I , 20 a),/
�• 185 , ot. Cilf IA , (,(9(P.A.Dit)
/•'•."iC3 �i
Notary
Seal
,. My commission expires CI leaBai
� •.�06 20 ..• �