NCC240755_FRO Submitted_20240319

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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
NORTH cnaOi.NA 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 Lots 75, 83, 86, 88 & 91 Prescott Manor Subdivision Phase 2
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
1232 Perry Bluff Drive 36.006191 -78.605966
1105 Delilia Lane 36.005308 -78.608420
Highway/Street1125 Delilia Lane Latitude 36.005709 Longitude -78.606389
1116 Delilia Lane 36.005220 -78.606993
1100 Delilia Lane 36.005085 March 1, 2024 -78.608247
3. Approximate date land-disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.8 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Keith Wood E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Cambridge Classic Homes LLC [phone]
Name(s) Telephone Fax or E-mail address
2113 Kinsale Meadow Lane 12339 Wake Union Church Road, Suite 100
Current Mailing Address Current Street Address
Wake Forest NC 27587 Raleigh NC 27614
City State Zip City State Zip
8. Deed Book No. 19526 Page No. 0642-0645 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):
Cambridge Classic Homes LLC [e-mail]
Name E-mail Address
2113 Kinsale Meadow Lane 12339 Wake Union Church Road, Suite 100
Current Mailing Address Current Street Address
Wake Forest NC 27587 Raleigh NC 27614
City State Zip City State Zip
Telephone [phone] Fax Number

fy a
ated agent in
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2. (a) If the Financially Responsible Party is not ein any action or le of Wake gal proceeding arising out of any
Wake County to receive any notice, process, pleading
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Not Applicable
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:
David Keith Wood/Manager/Cambridge Classic Homes LLC [e-mail]
Name of Registered Agent E-mail Address
2113 Kinsale Meadows Lane 12339 Wake Union Church Road
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
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.
•av!. ' h Wood j Manager/Cambridge Classic Homes LLC
Type or.41i - - / Title or Authority
r t—257— 2 6/
•':nature Date
1,4VIA1 L'` .W , a Notary Public of the County of " " �L C—'`
State of North Carolina, hereby certify that Y., \Otre:t appeared
personally before me this day and being duly sworn acknowledged that the above rmform was— executed by him.
Witness my hand and notarial seal, this .81 day ofV� , 20 P�1
ArayLWiKaen \/( ___..--- --------.
f ` Notary
• r ; Seal NOTARY PUBLIC �.
ti4-`�`. Wake may,NC My commission expires D r'
My Commission Expires February 02,2028