NCC241729_FRO Submitted_20240621

IOW 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
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 19 Jackson Manor
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co.or Municipality)
8704 Kimalden Ct
Highway/Street Wake Forest, NC Latitude 36.017540 Longitude -78.537350
3. Approximate date land-disturbing activity will commence: June 6, 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): .45
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Libby Hartsock E-mail Address [e-mail]
Telephone [phone] Cell# 919.624.8204 Fax# [phone]
7. Landowner(s)of Record (attach accompanied page to list additional owners):
CityScape Builders, Inc. 919.730.6634 [e-mail]
Name(s) Telephone Fax or E-mail address
P.O. Box 98926 8321 Bandford Way, Suite 007
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No. 16735 Page No, 2751 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):
CityScape Builders, Inc. [e-mail]
Name E-mail Address
P.O. Box 98926 8321 Bandford Way; Suite 007
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27624
City State Zip City State Zip
Telephone [phone] Fax Number 919.870.7094

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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 J Barrett [e-mail]
Name of Registered Agent E-mail Address
PO Box 98926 8321 Sandford Way; Suite 007
Current Mailing Address Current Street Address
Raleigh. NC 27624 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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 J. Barrett President
Type or print name Title or Authority
7/
4
'g'natur 7- Date
I, `f,IACUftk D CkC , a Notary Public of the County of L,)00
State of North Carolina, hereby certify that 1C i fc U jCa tT 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 2 day of Cu c,k , 20 24
Khanh Dac
NOTARY PUBLIC Notary
Seal Wake County, NC �^
My Commission Expires April 01, 2027 My commission expires l, 9 t( ( 202"4