NCC241239_FRO Submitted_20240422

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
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 PRESERVE AT JONES DAIRY AMENITY SITE
2. Location of land-disturbing activity: Jurisdiction WAKE CO. (Wake Co. or Municipality)
Highway/Street SHADOWDALE LANE Latitude 35.943583 Longitude -78.463968
3. Approximate date land-disturbing activity will commence: SPRING 2024
4. Type of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL AMENITY
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.67 AC
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name KB HOMES RALEIGH-DURHAM INC E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KB HOMES RALEIGH-DURHAM INC 919.422.8606 [e-mail]
Name(s) Telephone Fax or E-mail address
1800 PERIMETER DRIVE,SUITE 140 1800 PERIMETER DRIVE, SUITE 140
Current Mailing Address Current Street Address
MORRISVILLE, NC 27560 MORRISVILLE,NC 27560
City State Zip City State Zip
8. Deed Book No. 18362 Page No. 1235 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):
KB HOMES RALEIGH-DURHAM INC [e-mail]
Name E-mail Address
1800 PERIMETER DRIVE,SUITE 140 1800 PERIMETER DRIVE,SUITE 140
Current Mailing Address Current Street Address
MORRISVILLE,NC 27560 MORRISVILLE, NC 27560
City State Zip City State Zip
Telephone [phone] 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:
NIA
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:
R.SCOTT JOHNSON,SR.DIRECTOR OF LAND DEVELOPEMENT RSJOHNSON aAKBHOME.COM
Name of Registered Agent E-mail Address
1800 PERIMETER DRIVE,SUITE 140 1800 PERIMETER DRIVE,SUITE 140
Current Mailing Address Current Street Address
MORRISVILLE,NC 27560 MORRISVILLE, NC 27560
City State Zip City State Zip
Telephone [phone] 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.
R.SCOTT JOHNSON SENIOR DIRECTOR OF LAND DEVELOPMENT
Type or print name Title or Authority
2 . p -3 - 14 - . 5Z4-
Signature Date
I, RA ch c I Ca "cA k c (Ay— , a Notary Public of the County of Wake,
State of North Carolina, hereby certify that R. Scb f f ) 0ki1S ( 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 i Th day of �����( 20 Z'
Notary
L° �LK /1 C���G �C�
RACHEL CAVALEAR
s Tary Public, North Carolina Afro
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Wake County My commission expires A Pf o I 1 2a z/
My Commission Expires
April 19,2027