NCC241179_FRO Submitted_20240417

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
N , ,r; �f,,,w, 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 V(o OS LEGACY RlDGE
2. Location of land-disturbing activity: Jurisdiction WAVE . (Wake Co. or Municipality)
Highway/Street LEGetcy etOGE Latitude 3(o. Oz. 1 Longitude 7 S. Sot
3. Approximate date land-disturbing activity will commence:
4. Type of development(residential, commercial, industrial, institutional, etc.): ISlDEINAI-1
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .983
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name `KNLE JO41NS®N E-mail Address KV 12viLSIGi-icusrom oM{E'� NET
Telephone 1Ird - 53O - Otgl Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
RALE16H ckASTbM A-ta mE5 q'lIS- S -0141"1
Name(s) Telephone Fax or E-mail address
i 3G FAN-L. o F• N use RD S1"V 366
Current Mailing Address Current Street Address
1-E'6 NG 2't&15
City State Zip City State Zip
8. Deed Book No. ?' 3 n Page No. 519"" 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):
IZ�itrE16H CIAST"Gfi ttomeig IIJ 'K'1%Eft R'►RLEt&HCIASTZMttcivieS. NET'
Name E-mail Address
f 13G Fi1LtS ®F' NEtlSE R'D STE 305
Current Mailing Address Current Street Address
1ALE"I611 1\iCL 27(.I c
City State Zip City State Zip
Telephone (' t e)- 5"3°-0i'i-1 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:
fflMOTMI 1110M25oN -ritIA( leSfi-LE-16 CuSrbmil-lOMM . NIST
Name of Registered Agent E-mail Address
(.'13k F1gt•1.5 Or Neuse QD STF goo
Current Mailing Address Current Street Address
I2.1A1.Ei&ti tic, 2'1(.9 i5
City State Zip City State Zip
Telephone oile' 536 - 0141 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.
1
Type or print name Title or Authority
Sigur Date
I, Al ilL ;,4. #-t' , a Notary Public of the County of //4(
State of North Carolina, hereby certify that ® /45fi, appeared
personally before me this day and being duly sworn acknowledged tha(the above form was executed by him.
Witness my ha tprial seal, this /PI 'day of,, s'/� , 2O '/
p
a
T�-� (,0 otary
" Sale - /'
s`'.,` My expiresC f e 5.'P�7
° �i3L®O ,0*4,� commission
®®1 fie'°°'"• °°''°� ° "
,�°oa, CO oa i d��0 ��