NCC240957_FRO Submitted_20240403

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
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
IA CAROL INA 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 Buffalo Townhomes
2. Location of land-disturbing activity: Jurisdiction Town of Gamer (Wake Co. or Municipality)
Highway/Street W Gamer Road Latitude -78.622575° Longitude 35.715380°
3. Approximate date land-disturbing activity will commence: May 2024
4. Type of development(residential, commercial, industrial, institutional, etc.):Residential- Townhomes
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 8.0 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lewis Hardee E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Concept 8 Holdings LLC 919-604-5078 [e-mail]
Name(s) Telephone Fax or E-mail address
910 Tryon Hill Dr Ste 100 910 Tryon Hill Dr Ste 100
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
8. Deed Book No. Page No. 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):
Concept 8 Holdings LLC shawnconcepteight.com
Name E-mail Address
910 Tryon Hill Dr Ste 100 910 Tryon Hill Dr Ste 100
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Telephone [phone] 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:
Shawn Donovan [e-mail]
Name of Registered Agent E-mail Address
910 Tryon Hill Dr Ste 100 910 Tryon Hill Dr Ste 100
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Telephone [phone] 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.
Sha van Registered Agent
Type or pri a e Title or Authority
IA' '"),(-1-f 7,f'
Signature Date
1, i ..,-t..lkit,,s.. .1� . \C , a Notary Public of the County of L_.
State of North Carolina, hereby certify that pU ' t1 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 71 day of Moamik , 20 9.2`4
AMANDA MIX GA.).--- -AQ'.^ 11\-- '(-
' ' Notary Public Notary
..,` North Carolina
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