NCC241553_FRO Submitted_20240522

EV. 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
�z,, .An , ,;� 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 Vt.—g- PLA-_'r 'L
2. Location of land-disturbing activity: Jurisdiction t/JA ki<_. (Wake Co. or Municipality)
Highway/StreetGAR-f $14 °''1 Latitude 36"u(13O.E;g ' Longitude 7Sf'5 1(9kJ1'
3. Approximate date land-disturbing activity will commence: O/ /0-1
4 Type of development(residential, commercial, industrial, institutional. etc.): ( 3i/)f i r, L
5. Total acreage disturbed or uncovered (including oft-site utilities and borrow/waste
areas): 9,
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name . tc f1 Tt;F L, E-mail Address T1 eeL5PC?/At}(n,cat"
Telephone 1'i_719-1 s s' Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
(3ot 5 IQ S LLC
Name(s) Telephone Fax or E-mail address
2-71-( (OX/o2O fat-urn D2
Current Mailing Address Current Street Address
�✓11,1cE o(26s r` IQ t_ Z 7S37
City State Zip City State Zip
8. Deed Book No. 1`I 31-1 Page No. (j2.l-/Z2) 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):
SAt� aep 3f}ILL.i'
Name E-mail Address
21 2.J tc X/''2 3 (3 L u r t= o(z
Current Mailing Address Current Street Address
Ls/ Fof iS1 N• Z7s3 7
City State Zip City State Zip
Telephone 1( ' '1/7 - 6'( 7 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:
'., lea-V , C-6 Ve \
Name of Registered Agent i E-mail Addr s,,,..,€) 4-N F--4 i ,... Th 4 s ,„-;_),-t e_Q it
77- 1 p . : cb1..,v '
Current Mailing Add ess Current Street Address
s 14,9 ,ry
' c 7S
City State Zip' City State Zip
Telephone q i i I 7- )r-il
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.
Type or .nt nam � s
Title or A�ufhority
i
Signature 5 —�}
Date
I. ti<CtARA1 J/ Cq VLA. , a Notary Public of the County of (�) c
State of North Carolina, hereby certify that ,j c - ue
personally before me this day and being duly sworn acknowlee ed that the4ve form was executed by him appeared
Witness my hand and notarial seal, this ,/4\day of 20 a 1
�,,Ilillll//�,
�N HDa GllQiU JV [xll2�� y/d /���\ Notary
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NoTAR Y
My commission expires Ala 5p 0,•,.S.--
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