NCC241821_FRO Submitted_20240703

"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
County Unified Developmenthave Ordinance bbo
COUNTY sedimentation control planbeen completedefore and this approved
form byand an Wake Countyaccepta le Departmenter sion ofand
NORTH CAROL!NA 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 Preserve at Jones Dairy,South Lots 1.215
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Jones Dairy Road Latitude 35.943301 Longitude-78.464006
3. Approximate date land-disturbing activity will commence: 0410112024
4. Type of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):34.43
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jimmy Gaskins E-mail Address [e-mail]
Telephone [phone] Cell# 919-868-5391 Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KB Home Raleigh-Durham,Inc. 919.768.7988 nla
Name(s) Telephone Fax or E-mail address
1800 Perimeter Park Dr.,Ste 140 Same
Current Mailing Address Current Street Address
Morrisville NC 27560 Same
City State Zip City State Zip
8. Deed Book No.18362 Page No.1235 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):
KB Home Raleigh-Durham,Inc. [e-mail]
Name E-mail Address
1800 Perimeter Park Dr.,Ste.140 Same
Current Mailing Address Current Street Address
Morrisville NC 27560 Same
City State Zip City State Zip
Telephone [phone] 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 Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Doug Schwartz [e-mail]
Name E-mail Address
140 Shadowdale Lane Same
Current Mailing Address Current Street Address
Rolesville NC 27587 Same
City State Zip City State Zip
Telephone [phone] 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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue,Ste.550 same
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number 7227849
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
correct�edy information should there be any change in the information provided herein.
D
Type or print name Title or Authority
�nz ti�
Signatur Date
I, ZA\oc)i— , a Notary Public of the County of 3 uAI\
State of North Carolina, hereby certify that Uo�c � �•��,Ckc\'2— appeared
personally before me this day and being duly sworn acknow edged that the above form was executed by him.
Witness my hand and notarial seal, this )-3 day ofc ,\ , 20
ERIN N POLLOCK Notary
Seal NOTARY PUBLIC r�
Johnston County My commission expires dy
North Carolina
My Commission Expires June 17,2024