NCC241996_FRO Submitted_20240723

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
._ Le
N o person may initiateany land-disturbing activity on one or more acres as covered by the Weee
County Lintheo Devetoprnent Ordinance before this tom, and an acceol2b!e erosion aecl
NITy sedimentation control plan have been completed and approved by Wake County Department of
1 iI Environmental Services, Water Quality Division. (Please type or print and, if the question is not
'
applicable, place NIA in the blank_)
1. Project Name Lo— I
2. Location of land-disturbing activity: Jurisdiction \Ai( (Wake Co. or Municipality)
Highway/Street 13v I CI itnni a+. Latitude 15. qq 31f 50 Longitude -lg. 592010
3. Approximate date iand-disturbing activity will commerce: 1.0-lit ;ill-
4 Type of development(residential, commercial, industrial, institutional,
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): •50
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name &Arad'Lybeldi E-mail Address Sandie-Irche iv.Cr.
Telephone CM' t 10. 17 34' Cell# ,_,
Fax# -----
7 Lendowner(s)of Record (attach accompanied page to list additional owners):
Ktfirtr-raniaZi CL0.4 to4t. gle1•14111 • 2.116
_Igactziketeicify_tco"461-1-e•Cc".
Name ) Toeii Retezeirzi Telephone Fax or E-mail addrese3
'1 5i5 1446ea4rti ..1i,L10 1-•• Same
Current Mailing Address Current Street Address
V\64, ci9(44 t\\C 2'75 S'l sanu
State Zip City State Zip
8. Deed Book No. 0 lq 5 6 3 Page No. 012-1 b- 0 t2.1'Provide a copy of the most current d .
Part B.
Person(s) or firm(s) who are financialiy responsible for the land-disturbing activity (Provide a f-somprehensive list of all responsible padres on an attached sheet. Include requested information):
6lite,s4rn e Bkiid.,..„6 141_, ,...5 Cisykeltird)*At.re•C04-1
Name E-mail Address 1
g35//11) c5;( 'Oti IC IM•
Current Mailing Address, Current Street Address
PAlteill NIC. 2-1 1it5
City State Zip City State Zip'
Telephone 6114•Cif10 'f113`t 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-rnail Address
g
Gen ant Mailing M Current Street Address ___________
City._..M. State Zip City - ----
State Zip
Telephone Fax Nun-thee-
(b) if the Financially Responsible Party is a Partnership or other person engaging in business uncle- an
assumed name, attach a copy of the Certificate of Assumed Name. If the Finar-_'_'. ; le
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent g E-mail Address
351,291 S i x 615 Rd • Saxnf
Current Mailiinct Address. . _ F^ t Street Address
Current�.trW�4 Ad„r�ss
Ile-+ Ne 27016 Scott
City �� V StateCity
ry r` �9 � / Zip State Zip
Telephone "{ t`L • DIO''YW' Fax Number n) A
The above information is true and correct to the best of my knowledge and belief and was provided
d
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attomey-Era-fact, or if not an individual, by an officer, director, partner, or registered agent ith
the authority to execute instruments for the Financially Responsible Person). I agree to providr
corrected information should there be any change in the ihformation provided herein.
Type or , :: name f... Title or Auth
i° atur � 1 1`
� Date
rit la kill,/ &rt/P/AMV7
`` , a Notary Public of the County of �G,
State r s North Carolina, heresy certify Ghat. 7o /. ., el eiw., - 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 /0 ;ay of C GrW . 20
Elizabeth Basham No ary
IskEtftly Public Wake County,NC My commission expires i vV P7i(0
My Commission Expires 12/20/2026