NCC241164_FRO Submitted_20240417

IIIIPPIM
WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the 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
Nt„OFF,c,R"E,h, 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 (031 LEG C' RIOGE
2. Location of land-disturbing activity: Jurisdiction 1 4 KS (Wake Co. or Municipality)
Highway/Street t..e&Azii iztoc-e Latitude 3 CA• 'i2 Longitude n 1�• 5c%
3. Approximate date land-disturbing activity will commence: 4/5/24
4. Type of development(residential, commercial, industrial, institutional, etc.): rZE51DENtWtL.-
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): ,qq
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Cy LE J011N5ot.1 E-mail Address V 1LE@ IMILE1GtiCtASroM-1;totCS.t.\,ET
Telephone a113- 530- 0191 Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
R�LEeGN CusitM i-►OMEs IniC
Name(s) Telephone Fax or E-mail address
(13C9 FALLS OF tJEUSE RO scE 3o0
Current Mailing Address Current Street Address
R19 WI Gil ABC 2.1 Co 1 g
City State Zip City State Zip
8. Deed Book No. I1.22. Page No. Rol. 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):
RIALElIG+4 CU',r olve = oMES %NC- �cyLEo t(Z�tt.�tGJ c STOMi-iOMES. I�ET'
Name E-mail Address
(,13(o F A t..$' O F N EUS E TE 3 ---
Current Mailing Address Current Street Address
RV .Ei G+1 NC 21(015
City State Zip City State Zip
Telephone Ceite) 53a - 014'11 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:
ItM0111'I 17440MiSok TNv1 211,At-e1Gt-ic ASI-owt-totya. NET'
Name of Registered Agent E-mail Address
G13(D M=141.Lc or NEuS E R'+7 ST6 .3oc --. -.
Current Mailing Address Current Street Address
gf3`FIGi4 NG 21C0 1G __ __ .
City State Zip City State Zip
Telephone Cite' 53° ~ cilq'1 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.
-rime W1 ThoM'SON pMZ srtaENT
Type orprint name Title or Authority
3—ii-z cif
Sic, hature > Date
I, i1wfll{N ,�JS
/J'�(�/�
F1/� , a Notary Public of the County of piZthQ
State of North Carolina, hereby certify that /#/ L cln appeared
personally before me this day and being duly sworn acknowg d thhe above form was executed by him.
Witness my hand and notarial seal, this // day of Ara 20 P-t`
so..,..,.. '•.,‹�rm , ,may`�
.4, 0TA.g � Notary
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a My commission expires —�—Whi
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