NCC240538_FRO Submitted_20240223

"WM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
,w No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countyseimentation Unifiedcontrol Development c bbo
COUNTY dn haveOrdinan been completed eefore and this approved
form byand Wake Countyaccepta le Department ofand
NOR III(:ARUIINA 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 NameTI(PSIe1c\ Sir 1 crtS ' -I- IN , ( IS- II11 I18- I4(0 EZ6'1 20
2. Location of land-disturbing activity: Jurisdiction ' OIPSv i I I G (Wake Co. or Municipality)
Highway/Street l ,QA �Wye, Latitude3S,or-it Longitude ^ 1 g, `KP Z
3. Approximate date land-disturbing activity will commence: 1/A0 f L I 41- 02
4. Type of development(residential, commercial, industrial, institutional, etc.): }Rtctote VrrkLi
5. Total acres a disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1,'3 Z
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1 E-maila.Cl v1S Address ohi.S 6)0,{rhbrhn. Corn
Telephone Cell � C' ' t t'_2t(03
p # ( l Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
D.2, Dor n , )NIC
Name(s) Telephone Fax or E-mail address
�Zd g -rot11s o-CKt sR--TdSke.2o\
Current Mailing Address Current Street Address
el)NQ e Ca1� I\I L r,2v LD I S
City State Zip City State Zip
8. Deed Book No. 01"1nn 505 Page No. 2A c(-1 2.3 rovide 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):
\-\tAoil INL 12 niiivNyhOr vis�yN --mkV 1S \id((ht, (+fon �c
Name E-mail Address
ZO Y `ra.11 c o� N- sasi,Ste.,Id1
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone R 1" I �3 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:
C.T. C0(�p ra,h _
Name of Register d Agent E-mail Address
I (.o O (yl r t CO ZOO
Current Mailing Address Current Street Address
C alp.; . �L a�[A,c
City Q State' Zip City State Zip
Telephone vl 1 I - U-4 4- 4'7 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.
Typ or print name <- Title or Auth rity
),(Ar\ - 5- 20
Signature Date
I, (-11/A.A1-- m 57Si(v(o , a Notary Public of the County of $-1 9'--
State of North Carolina, hereby certify that]gC(1 M. 'DAVI'S appeared
personally before me this day and being duly sworn acknowledg d that the above form was executed by him.
Witness my hand and notarial seal, this 5 day of , 20 02 !
P -.tnors,
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� � Notary
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