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HomeMy WebLinkAboutNCC241708_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 cbsawyer@gmail.com Telephone (919) 772-5294 Cell # (919) 427-8803 Fax # N/A 7. Landowner(s) of Record (attach accompanied page to list additional owners): c9r1 Holland's Church (919) 772-5294 y2 3 303 cbsawyer@gmail.com 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 cbsawyer@gmail.com 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 (919) 772-5294 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, (919) 772-5294 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 , '