NCC241626_FRO Submitted_20240530

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
ty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimCounentation control plan have been completed and approved by Wake County Department of
NORTH CABOI.INA 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 Lot 4 Gardner Farms
2. Location of land-disturbing activity: Jurisdiction Wake CouIty (Wake Co.or Municipality)
Highway/Street 8724 Maxine St Latitude 35.5383503 Longitude -78.7226876
3. Approximate date land-disturbing activity will commence: 5/10/20 24
4. Type of development(residential, commercial,industrial, institutional,etc.): Resident'al
5. Total acre^rs disturbed or uncovered (including off-site utilities and borrow/waste
areas): .39 ac.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rich Sherman E-mail Address [e-mail]
Telephone Cell# 919-422-2838 Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
New Home Inc., LLC 919-239-4747
Name(s) Telephone Fax or E-mail address
1611 Jones Franklin Road, STE 101 1611 Jones Franklin Road, STE 101
Current Mailing Address Current Street Address
Raleigh NC 2.760. 6 Raleigh NC 27606
City State Zip City State Zip
8. Deed Book No._018017 Page No. 02393 _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):
New Home Inc., LLC [e-mail]
Name E-mail Address
1611 Jones Franklin Road, Ste 101 1611 Jones Franklin Road, Ste 101
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
CityState 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 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:
�..Richard L. Van Tassel II. _ rshermanAnewhomeinc.com
Name of Registered Agent E-mail Address
1611 Jones Franklin Road, Ste 101
Current Mailing Address Current Street Address
Raleigh NC 27606
City State Zip City State Zip
Telephone [phone] Ext 102 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.
Richard Sherman Manager
Type or rip nt name Title or Authority
�1(7/�� U` J 4i 19/2024
Signature Date
I, . .1 lar/ 1&. C(( try vd , a Notary Public of the County of _Wet'/46,
State of North Carolina, hereby certify that i Meta S N)01,1., 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 PI day of 4priJ_ ,20
NARY K CLIFFORD 1 )
NOTARY PUBLIC ). (,�- �/'
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• WAKE COUNTY Notary !'
STATEW NORTH CAROLINA 1
My commission expires re-4 0/.mooq