NCC241581_FRO Submitted_20240523

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
m Ordinance
COUNTY sedimentation
CountyUnified control planDevelop ent have been completedbefore andthis approvedform byand an Wake Countyacceptable Departmenterosion ofand
NoR, +, kROI 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 Barony Lot 6
2. Location of land-disturbingactivity: Jurisdiction Wake Co. (Wake Co_ or Municipality
y p y
Highway/Street Barony Lake Way_ Latitude 35.9601993 Longitude 78.6860454
3. Approximate date land-disturbing activity will commence: 4/30/2024
4. Type of development (residential, commercial, industrial, institutional, etc. ): residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas • 1 .02
6 Person to contact should erosion and sedimentcontroLissues arise during land-disturbing activity:
Name Yasir Syed E-mail Address yasyed518C gmail.com
Telephone Cell # (919)2259869 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners).
Name(s) Telephone Fax or E-mail address
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. 16740 Page No. 2329 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):
Yasir Syed [e-mail]
Name E-mail Address
441 Chickasaw Rd
Current Mailing Address Current Street Address
Durham NC 27703
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:
Name E-mail Address
Current Mailing Address Current Street Address
City Stdte 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Yasir Syed Owner, General Contractor
Type or print n e Title or Authority
2`' 4-1 -2024 —
Sign re Date
I, iliN(YA OxGhl_z__ ___�A � , a Notary Public of the County of c/k(V)(,1N(\
State of North Carolina, hereby certify that L (k , W J((I 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 1I tAil day of AT � I , 20 2-Li__
AMINA RICHARDS Notary
tl@dry Public I ��� 1 � b2-111
Durham Co., North Carolina My commission expires
My Commission Expires Dec. 28, 2027