NCC240617_FRO Submitted_20240301

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
„0 SEDIMENTATION POLLUTION CONTROL ACT
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. II
1. Project Name 1.Q50t+ r Farms Sdiv ,'v
2. Location of [Ake,
activity: Jurisdiction Wa 4 Cpo�v► � (Wake Co. or Municipality)
Highway/Street A'GI�} Lk ke, i-oL Latitude 3 c Iu(1 Longitude "75.7110
3. Approximate date land-disturbing activity will commence: i/((24
4. Type of development(residential, commercial, industrial, institutional, etc.): INe-5 i den'f;a
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): ZI.t�
6. Person to contact should erosion and sediment control issues arise duringland-disturbing activity:
Name Fc leJ4(s E-mail Address -QC el .n0a(CS rPst(f),(00-,
Telephone I1 I D- L4 5 . 8 O ( Cell# Lj 10•t( . flo ( Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
To LAskfcr L-1 � o 4rtd Shekl) LiI0. 59.sN0 irmoaldresi tc
Name(s) Telephone Fax or E-mail addre s
a Z7 NtSm 54 yVI.Q u MNd it n�
Current Mailing Address Current Street Address
rl;lt+r1 M(D 211 I I
City State Zip City State Zip
8. Deed Book No. I9-1 o Page No. 24743 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):
7?)4- CA5A:frJ- PLC_ 41rrrA eo�(�s ft,• C��_�o,r•
Name E-mail Address
Current Mailing Address Current Street Address
,M 2 c/ (l
City State Zip City State Zip
Telephone 41.0•`(S 1 . B`f v k 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
�zlo lirlvfo.,1 � (Po� sit log 5t 4 a) Mai <��
Current Mailing Address Current Street Address
1¢^;o�.f dale- p1-L- 2159
City pi- State Zip City State Zip
Telephone 9 8 l" 2D-D - 210 , 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:
N A/
Name o 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.
Fr G&I,C S ¢ ref, ic,t 4(5o
Type or p int name Title o uthority
2t 13/Z o
Signat e Date
rCO3 AO ,0,.c.S-5011 , a Notary Public of the County of IsiarAi�C
State of 44544 CaPatina, hereby certify that Era SItltc..-LIMS 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 /3 day of FA/5/20 1/2y , 20 ZN
Notar
Seal
Nicholas Jackson My commission expires /v /ay-4-7
NOTARY PUBLIC
Harford County
MARYLAND
MY COMMISSION EXPIRES October 10,2027