NCC242009_FRO Submitted_20240723

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i,;it„.,.*Vit-Y4f14':2-r- WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
I
I No 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
n_ - ----1 applicable, place WA in the blank.)
Part A.
Project Name t-Vet 22 , Sant 4 t to A5 a-4- IN2F-e Mr-ele-v-
2. Location of land-disturbing activity: Jurisdiction Vjakc _(Wake Co. or Municipality)
r.
Highway/Street28321+WESA Pion W Latituoe 36.1V/5q1 Longitude -rig•teill50o
3. Approximate date land-disturbing activity will commence: 6 iF12j'a
4. Type of development(residential, commercial, industrial, institutional,
5. Total acreage disturbed or uncovered (including off-site utilities and borrowlwasie
areas): •tic)
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 561.4 e, Lincil E-mail Address 61/lei( cil At fir zorn
Telephone q14 -stio .ivi34 Cell#
Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
MOltiE. Shi AA &Act si>vu4e/will;tirn Let Chi 44 161-ZJ!6-36P2- _____,,AbtekkLpi&qtYrtil•C_P ril
Narne(t) Telephone Fax or E-frail address '
A 54*
—
Taw-rent Mailin Address Current Street Address
Actitaik t\I(. 2/1/9 b 3 savm
___
.....
City State Zip City State Zip
8, Deed Book No. 01 q 51 i Page No. Oa..Eqg Provide a copy of the most cerrent need.
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):
i 6 nt titifeebi LI-C., bbIlt..e
Name E-mail Addr-ss
____a5Ltee2fAL___
Current Mailing Address Current Street Address
Ralellr, (\IC. 1let5
ck,y, 3 State Zip City State Zip
Telephone_ qt4•VI o • cm V 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Nurriber
(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:
3.-D 04.-1-hlin 1-?>1Ve\S-tv.ne 1011(-69 oc. r(. c_erwi
Name of Registered Agent E-mail Address
0`.Y2 -2- dLc_c, _ c-Avh,e,
Current Mailing Address Current Street Address
Al,e;ik tC, 7511/15 5c. 4„
City 3 State Zip City State Zip
Telephone C(Let "52.10 111V/ Fax Number r\J 1
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 chance in the information provided herein.
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k 11 II tie- Avv*e-
_____,...3,
Type or c- ame Title or Authori
/ — Date
... , --
I, da6MILi' QatkiterWIMA , a Notary Public of the County of vvatc-e,
State of North Carolina, hereby certify that ‘dohof4+1041 autshAkt.... appaared personally before me this day and being duly sworn acknowledged that the above foam was executed by him.
Witness my hand and notarial seal, this Z1C4'da aid. , 20 24 /
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Jasmhe Sawyer Llama y
Notaty Public
Wake County,NC
. \ smmission expires I r).. Rod
My Commission Eiq3irss 01/27/2027