NCC241160_FRO Submitted_20240416

WWI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
rillill.'"-- 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
j COUNTY 1 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
-- --- -I applicable, place N/A in the blank.)
Part A. t C
1. Project Name I �J�- PUnJ -TO -
l '
2. Location of land-disturbing activity: Jurisdiction W pi-N die,\ \ (Wake Co. or Municipality)
Highway/Street 1(032- L.I.Spc„.. Latitude 3SW 110 GI b Longitude - 178 M Z8 U3b
3. Approximate date land-disturbing activity will commence: 3/i OA
4. Type of development(residential, commercial, industrial, institutional, etc.): .sr ,1,a1 6 P"1/-
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): ,ZS
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
•
Name ?ceSiiiin ?erc7 E-mail Address Preb� cU
r\Q?tr€, Nue,CvNI
Telephone 1-4 3-S1513 Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Grey AAQrb e114 , :11, 1, 61 (9I-3V" 31i3 Cmil Herb b &(,-n^U�.earo
Name(sy Telephone Fax E-mail address
1'133 ern s Ln i- 33 /}- � � 1,,r,, - ,
Current Mailing Address Current Street Address
\ „Ck,\0 fi L VI I `4.e.,��1 NVL 7,7 Yt 1
City State Zip i City State Zip
8. Deed Book No. 1 0 -1} t
J b _ Page No. 1 O 3 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):
'Pine, *\e- co„s4- 0,, 6-,,p LLL e?ces4vme ?,AosfA 6c...10.(:,../s.,
Name E-mail Address
1114 NC Li.-7 119(4 NG 4Z
Current Mailing Address ') Current Street Address /�� ^�
�1,i. c0-�! •Qc i� Pk.. (/75-q& V i\lI 0 ra�yy J r L Z I ””-
City ` J State Zip City -J State Zip
Telephone VA- y` -- )---5( Fax Number

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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:
?'1 Kai Skit. Co...sif w{;um 64 z`4° Ir LI-, TresL e ;re... -k-,Aei r_p-.)61
Name E-mail Address
ICic1Nf N& k i' lt1 N Aft— 4 Z/
Current Mailing Address Current Street Address
CityState Zip City State Zip
Telephone q(9-(46"5 7r- 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:
-301/4.MZS 2 yy✓✓e_r •
?re,5L,e ?;co-irk, Cdn'1
Name of Registered(Agent E-mail Address
\iCtq N� La/ Iiy'i N k-z,
Current Mailing Address Current Street Address
v \vk, NL. 1,7�31 L' \,.i,k\o�, '; A/U 2?�-11 -'
City J State Zip City '3 State Zip
Telephone 1(6( vi 13--3 5/C" 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.
Pre On Pexr� Me1M beY 1 vv1 an aqP-r
Type or print name Title or Authority J
Signature Date
I, 5c ioi. V '1-0t?k4 '-oMero a Notary Public of the County of tn10.14--E
State of North Carolina, hereby certify that pre -on Fey-' 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 IA-WIN day of Maxon , 20 2-l-k
Soria V T&'t0. p_odv1erb
Notary
Seal
SOFIA V TAPIA-ROMERO My commission expires 12111-1 l/ O2-g
NOTARY PUBLIC
Wake County
North Carolina
My Commission Expires December 14,2028

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