NCC241515_FRO Submitted_20240517

"WI 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
NOR �,�F„ �,,� Environmental Services, Water Quality Division. (Please type or print and, if the question is not
I IIapplicable, place N/A in the blank.)
Part A.
1. Project Name Halifax Road Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Halifax Road (SR 2303) Latitude 35.95038 Longitude-78.71377
3. Approximate date land-disturbing activity will commence: April 2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):4.66 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dennis Cyrus E-mail Address [e-mail]
Telephone [phone] cell # Same Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Halifax 21 , LLC 919.669.5933 [e-mail]
Name(s) Telephone Fax or E-mail address
5000 Falls of Neuse Road Suite 100 Same
Current Mailing Address Current Street Address
Raleigh NC 27609-5
City State Zip City State Zip
8. Deed Book No. 19147 Page No. 1463 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):
Halifax 21 , LLC [e-mail]
Name E-mail Address
5000 Falls of Neuse Road Suite 100 Same
Current Mailing Address Current Street Address
Raleigh NC 27609-6aE Same
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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:
James Allen, Jr. jim@jimallen .com
Name of Registered Agent E-mail Address
5000 Falls of Neuse Road Suite 100 Same
Current Mailing Address Current Street Address
Raleigh NC
City State Zip City State Zip
Telephone [phone] Fax Number n/a
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.
David M. Cyrus Member/Manager
Type or print name Title or Authority
' ature Date
I, ka noj, Al Act/let` , a Notary Public of the County of VainC,e,
State of North Carolina, hereby certify that V id iv\ C L1(( ' S appeared
personally before me this dayand being dulysworn acknowledged that the abode form was executed by him.
P Y
Witness my hand and notarial seal, this Co day of NOV er \lo Cy- , 20 2.3
‘``‘ N HAS c�'� Notary
Seal P;�'oon EX,�•.,
? a i :..: My commission expires fO 3 1
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