NCC241162_FRO Submitted_20240416

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
N4 ,. F .:, ,,«,� 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 102-j LEGACY Rtt �.-
2. Location of land-disturbing activity: Jurisdiction ? e (Wake Co. or Municipality)
Highway/Street LEGAC1 RIOGe Latitude & • 0S Longitude • S .
3. Approximate date land-disturbing activity will commence:
4. Type of development(residential, commercial, industrial, institutional, etc.): RE6‘051%411 ,
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 'i01 LE J Oti NSO E-mail Address 1.0 CViST11t-A tie NET"
Telephone oi1e- 530 - 0011 Cell# — Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
1Z1j -1-51C71'1 CuSTDm °noun , 1K1C
Name(s) Telephone Fax or E-mail address
L013 4, rigt.s OF N 51/1 s E OD STIr 3'o
Current Mailing Address Current Street Address
RVir t.Vt eoti 14 C 21.115
City State Zip City State Zip
8. Deed Book No. h 322 Page No. + '1 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):
grtt-ElGti C1nSTOM • toI-'6S INC WILCP K yli.E.1G1-1CVtg'R}iN1-rio
Name E-mail Address
&j 13to rWl.45 OF NEUSE 120 sr ?cc,
Current Mailing Address Current Street Address
4�t1,1r►C�ti NC 21(91 S
City State Zip City State Zip
Telephone (Cci I ) 530' 1q1 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:
ItMOT I ThOMtescN Ma® gt4+-etG cvls rt.mt•1opnES. t-EC'
Name of Registered Agent E-mail Address
(o'13G I—'1f:V1-1..,$ OF NEIASE t2V0 Ste' Soo
Current Mailing Address Current Street Address
121441.E 16 NG 21Cot
City State Zip City State Zip
Telephone ( � ' S 3u" O t 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.
T'IMOn1 imtosot•J 9a5stost,ri
Type or print name Title or Authority
• l
Sig at re / Date
I, AL,w',1 h ( .4�/e , a Notary Public of the County of XQ
State of North Carolina, hereby certify that 1 '0,e7c/./ �zt/J/#' appeared
personally before me this day and being duly sworn acknowlepiged that the above form was executed by him.
Witness my hannonaltarial seal, this /I=~ day of /IQ/'G1( , 2021
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Seal
pUB�,� , ••` •® My commission expires