NCC241279_FRO Submitted_20240507

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
fine D b and
COUNTY sedimentationCountyUni ed control planevelopment haveOrdinance been completedefore and this approvedform byand an Wake Countyacceptable Departmenterosion of
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable,place NIA in the blank.)
Part A.
1. Project Name Lot 2 11.e Overlook o* Mow+ Vernon
2. Location of land-disturbing activity: Jurisdiction Wake Cou.r`47 (Wake Co. or Municipality)
Highway/Street N .Vcrnon Ckurch Ra• Latitude 35•`11(n8 21 Longitude 1 g•69 34108
3. Approximate date land-disturbing activity will commence: 2-I Ll-241
4. Type of development(residential, commercial, industrial, institutional, etc.): res iden+iol
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): O.co
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ro1oer Ke%t-h E-mail Address r [e-mail]
Telephone Cell# (ci t9)5 Z 4-3'1 24 Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
Ke;k1" CUs+om Constrc,ction LLC. N9)57)1-3?2y rkem,cons+rgcti ono y4t oo.CD nn
Name(s) Telephone Fax or E-mail address
2 10 5 Le90 e C+-, Lcgo...-e Ca-•
Current Mailing Address Current Street Address
Raie.% C 27(0!3 Rc\e<y„ N C. 27(o13
City State Zip City State Zip
8. Deed Book No. ci 30 5 Page-No, 2.4,1 b 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):
Ke 04, CAL 540 rv-, ConSlruh.c+ion U-C, rkeitk,cons+rukc+iorN(Plo- .00.Co►n
Name E-mail Address
2905 Lec30.rc CA-. 2905 LeSgarc +,
Current Mailing Address Current Street-Address
rJC 274,i3 Rale� 1-.. NC. 711,13
City State Zip City State Zip
Telephone (919\5 Zr-t-372 4 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:
Robes- rke:t tr.consA-ru.c_-tiorcyal,00•Corn
Name of Registered Agent E-mail Address
2905 Le c.•e c+, 2905 Lelare G+.
Current Mailing Address Current Street Address
(�0.1ei NC 27co13 R0.1e `. Nc 1-7L, 13
City State Zip City State Zip
Telephone( I19 529-372Li 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.
Robe+ 1<er Owner I Membcr
Type or print name Title or Authority
2-1 y -Z`-I
Signature Date
I, COWWI V `�
S , a Notary Public of the County of a Kei
State of North Carolina, hereby certify that Rl)r.t-f -1— �" e 1 '1 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 day of 1)o1iiti , 20 gi
CAR�NEI.LE C HENSUN Notary l /
e tary PublicMy commission expires 1
Granville Co.,North Carolina
My Commission Expires Nov.2,202'