NCC241735_FRO Submitted_20240618

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
SNAKENo 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
a,,,,,,,,,,,,i i , 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_ `03 to ?U� .�6
2. Location of land-disturbing activity: Jurisdiction al - k\ (Wake Co. or Municipality)
Highway/Street 1 6 41 43'tl'''r atitude_ 5- Ygi37_ Longitude -7o•9 z-9 33G
3. Approximate date land-disturbing activity will commence:_ 6.4
01
4. Type of development(residential, commercial, industrial, institutional, etc.): rdie iNco s P-i-
5. Total acreage__ disturbed or uncovered (including off-site utilities and borrow/waste
areas): .a r.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ?ces* ?err E-mail Address ?��rsQ 1?rne,*Ael NIL(4m
Telephone 119-'413-55 IS Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Gray A-Verb e3r ,eA 61 (9I-3V- 3�(?3 c Hey pG I.cQM
Name(sy .J. Telephone Fax E-mail address
\'13 3 �r C 6( Gt) 1733 r„ t( L'
Current Mailing Address Current Street Address
\,I-e„CSt,`\ P L Vi I ue.,a.QA1 imL -z?511
City State Zip i uCity State Zip
U 1
8. Deed Book No. '0 4 510 Page No. l0 3 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):
rPerv2, e- c 0A4RA,i;oe, (,_,gyp Lilt- �(1s4rNe ?;Aosf4 6a .c,"
Name E-mail Address
1114Pik- 4-2, 194 NE- 4
Current Mailing Address Current Street Address
F
U .�\.04 't� Nc, ?/7S�L '�rrllciL, ,((��y � 27s2-
�r
City ) State Zip City J State Zip
Telephone VA— kV Y ( 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:�inni�zk. Co•Sifw E.;uR `4u-p � ?rei e ,tse..,5koAe. loan-"'II
Name E-mail Address `J C
19''f
Current Mailing Address Current Street Address
City J State Zip City \ State Zip
Telephone (IV-44( C 57S` 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:
DCA.M r'S . yer ?recOfir\ e02,5 k,64.0,-t) wry
Name of RegisteredlAgent E-mail Address
11/416tUk iv LA-1/ ��i'I NL k '
Current Mailing Address Current Street Address
\,i,A<a/ NL 1,7 �� \,t,l��, �rr�� /J- Z 75'1Z-
City State Zip City J State Zip
Telephone I t 1 J i�i'"J / 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.
Pre5fon Tc ok J Eview 1'�eY 1 Manley
or print name Title or Authority J
3111-02.1-1
Signatur ___ Date
I, Stciok. V "To, t4 'I O'€rp , a Notary Public of the County of Wad
State of North Carolina, hereby certify that arebkon Vie'-' 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 11-Wh day of M0.rc'n ,20 2u
Sc)Qio. V —r iq j�oNten,
Notary
Seal
SOFIA V TAPIA ROMERO My commission expires r'2)/ -I /ZO2 g
NOTARY PUBLIC
Wake County
North Carolina
My Commission Expires December 14,2028