NCC240366_FRO Submitted_20240212

WPM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
•SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County 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 NameSIVANERI RESIDENCE
2. Location of land-disturbingactivity:Jurisdiction WAKE
(Wake Co.or Municipality)
Highway/Street STREAM MANOR COURT Latitude 35.901 700 Longitude-78.494590
3. Approximate date land-disturbing activity wilt commence: FEBRUARY 1,2023
4. Type of development(residential,commercial,industrial,institutional,etc.):RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):a95
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name VAIBHAV JAIV E-mail Address [e-mail]
Telephone Cell it 919-633-0681 Fax# [phone]
7. Landowner(s)of Record(attach accompanied page to list additional owners):
KEERTHI SIVANE RI&NITHYA SEETHARAMAN 917-495-1670 [e-mail]
Name(s) Telephone Fax or E-mail address
8221 BROOKINGS DR 8221 BROOKINGS DR
Current Mailing Address Current Street Address
CHARLOTTE NC - CHARLOTTE NC 28269
City State Zip City State Zip
8. Deed Book No.019506 Page No.02395 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):
SHAIL CONSTRUCTION LLC [e-mail]
Name E-mail Address
114 TEALIGHT LANE 114 TEALIGHT LANE
Current Mailing Address Current Street Address
CARY NC ,5i CARY NC 22513
City State Zip City State Zip
Telephone [phone] Fax Number 919-882-9077

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
' MAN 0 T TPJ-- N [e-mail]
Name of Registered Agent E-mail Address
114 TEALIGHT LANE 114 TEALIGHT LANE
Current Mailing Address Current Street Address
CARY NC CARY NC
City State Zip City State Zip
Telephone [phone] Fax Number 919-882-9077
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.
MANOJ JAIN MANAGING MEMBER
T e or print name , ^c , Title or Authority
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n ure Date
I, K c -e E Pr I V Cf Y e , a Notary Public of the County of JO h n s T-o n
State of North Carolina, hereby certify that ►Ulan of Jain 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 Zq'day of J tit Y1 tit GI 111 ,20 2
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January 29,2024
Re:Grand Highland Estates Lot 50:1816 Stream Manor Ct.Wake Forest NC
To Whom It May Concern,
Keerthi Sivaneri,as owner of the above referenced lot,gives permission for Shall Construction,LLC to pull erosion
control and sediment permits,and any other permits related to the construction of the home on the referenced
lot.
Please feel free to call me if you have any questions.
Sincerely, 131l e y� .,.�11 A
'eerthi Sivaneri
K<Ate Esmerollola rvolre .a Notary Public of the County ofJOht i i_._.
State of North Carolina,hereby certify that K et rtt i_5I VGf nevi appeared personally
before me this day and being duly sworn acknowledged that tile ill form was executed by him/
her,Witness my hand and notarial seal,this Zq ilnv of JptXlt 1U rl7 ?fi
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