NCC241708_FRO Submitted_20240619

!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
N«}, l{ ;,E,,,,; ;, 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 Holland's Church Parking Expansion
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Ten-Ten Rd. Latitude 35d39'10"N Longitude 78d39'35"W
3. Approximate date land-disturbing activity will commence: June 2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Church
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1 .8 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Sawyer E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
c9r1
Holland's Church [phone] y2 3 303 [e-mail]
Name(s) Telephone Fax or E-mail address
4701 Holland Church Rd. 9433 Ten Ten Rd., Raleigh, NC 27603
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
8. Deed Book No. 19255 Page No. 146-151 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):
Holland's Church [e-mail]
Name E-mail Address
4701 Holland Church Rd. 9433 Ten Ten Rd., Raleigh, NC 27603
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Telephone [phone] V2 1 c 3 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 Wa e 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 cop of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give n e and street address of the Registered Agent:
IV/
Name of Registered AgeyIt 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.
Chris Sawyer Holland's Church Trustee Chair
Type or a Title or Authority
-Signature Date
I, ,)e5t f
C 4 b- IN 0-e_ , a Notary Public of the County of ',.�,t✓
5 •
State of North Carolina, hereby certify that ��. V c 1 -X:(.W e(-- appeared
personally before me this day and being duly sworn acknowledged that tie above form was executed by him.
L day of
Witness my hand and notarial seal, this ful\ay , 20 2,-:�
J
",, ji)44.40(2i-/
-, �6' '- Notar
co /i /2'RY.P�
Seal.441 • ' O
Z. :=0 MY (,n' 1. My commission expires ) Z -.2-2-0 Zf-)
COMMISSION
7. c- EXPIRES V
`• 12/2/2025
.
ON CO\

STATEMENT OF LANDOWNER CONSENT FOR LAND DISTURBING ACTIVITIES
Date:
Project Name Holland's Church Parking Expansion
Financially Responsible Party: Holland's Church
Parcel Identification Nos/Addresses: 1609122919-9433 Ten Ten Rd., Raleigh, NC 27603
Owner Contact Information: cbsawyer©gmail.com, [phone] 9/ ?- - % of
Wetherill Engineering, Inc.
As the landowner of record for the above referenced property(ies), I authorize
to submit an erosion and sedimentation control plan and to conduct the anticipated land disturbing activities.
Chris Sawyer Holland's Church Trustee Chair
Type or print r�.ar 1e Title or Authority
� Jam,
Signature Date
6 e S[- �'_ , a NotaryPublic of the Countyof \kt
I, ,jC&
State of North Carolina, hereby certify that C-1M �`� ���'w � appeared personally before me this
day and being duly sworn acknowledged that the above form was executed by him/her.
r r+
Witness my hand and notarial seal, this '30 day of )ti'\CzNi , 20 ,-L•:3
• N ary
' 2 Y
M
COMMISSION
OMMlss oN U ' My commission expires Z. -
EXPIRE
/1/srONO•.0
, '