NCC241232_FRO Submitted_20240422

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
m, rr,t t t,im
, 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 CA O1 LEG14CA1 MPG
2. Location of land-disturbing activity: Jurisdiction V,91A%<5 (Wake Co. or Municipality)
Highway/Street LEGKol 12ID66 Latitude 3Ca •O2. Longitude -'1cd. 5q`-
3. Approximate date land-disturbing activity will commence: 4/8/2024
4. Type of development(residential, commercial, industrial, institutional, etc.): R.EciD ;t T\
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): ,5'343
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 't<y 3Ot11,1561, E-mail Address ytE c IR iFIL- 'tGr-IctnScbM4 3MES.
Telephone cl IS- 530- 0 i I 1 Cell# Fax# -
7. Landowner(s) of Record (attach accompanied page to list additional owners):
i2ALEIGI-I Ct4S1-01v1 1-torlAES tNC
Name(s) Telephone Fax or E-mail address
Fi4t OF NEW 360
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. Page No. 3 33 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):
r2AA LE t C,H CV STO -t-1OMV5 i4 `k`A G IH C tAS ONI liONIEC . N tT
Name E-mail Address
(,13 to FWt_t_5 OF N EL 5E 14.D S1 /ob
Current Mailing Address Current Street Address
RrA1e't6ry 21(32 15
City State Zip City State Zip
Telephone Cgl ) 5.30- ( I 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:
-rim anisi ` -10m,P.SoN r1`vVA. RILL I6 cAAsiz ,otAe . Nir
Name of Registered Agent E-mail Address
6'13(0 FYI-Li-5 Ot= rid,'sr Rp srs 3cc
Current Mailing Address Current Street Address
Ptf4L 9G+H ts,; 27C015
City State Zip City State Zip
Telephone q( - 530 - O%q1 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.
ell e W• io
• 1 reuuna3`l✓�
Type or print name r Title or Authority
• 3 -/1-Zt/
Sign r Date
I, /a 4'7/[t,_ji fi!(/ , a Notary Public of the County of t�o/ff(
State of North Carolina, hereby certify that .`lqI 1,44Affh appeared
personally before me this day and being duly sworn acknowleed tha the above form was executed by him.
Witness mxr,i Ytfi tarial seal, this //-) g day of ft h , 20 Pt
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I•. 4,,E3 .�� My commission expires c��,7
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