NCC242240_FRO Submitted_20240724

11: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
NORTH cnaOi.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 35 Prescott Manor
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 917 Harrison Ridge Latitude 36.00893 Longitude -78.61128
3. Approximate date land-disturbing activity will commence: 1-2-23
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.56
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Craig Roark E-mail Address [e-mail]
Telephone Cell # 252-469-1878 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Grande Manor Homes, LLC. 919-868-4720 [e-mail]
Name(s) Telephone Fax or E-mail address
1151 Tarboro Rd. 1151 Tarboro Rd
Current Mailing Address Current Street Address
Youngsville NC 27596 Youngsville NC 27596
City State Zip City State Zip
8. Deed Book No. 018594 Page No. 01631 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):
Grande Manor Homes, LLC. [e-mail]
Name E-mail Address
1151 Tarboro Rd 1151 Tarboro Rd
Current Mailing Address Current Street Address
Youngsville NC 27596 Youngsville NC 27596
City State Zip City State Zip
Telephone [phone] 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:
Trevor D. Brandt, Attorney [e-mail]
Name E-mail Address
PO Box 2108 417 S. Main Street
Current Mailing Address Current Street Address
Wake Forest NC 27588 Wake Forest NC 27587
City State Zip City State Zip
Telephone [phone] Fax Number 919-249-5130
(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:
Christopher Davis [e-mail]
Name of Registered Agent E-mail Address
808 Lake Royale
Current Mailing Address Current Street Address
Louisburg NC 27549
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.
Christopher Don Davis Member/Manager
Type or print nam Title or Authority
Signature Date
�. 1 V 'L• e \f a cisse . a Notary Public of the County of Fra /LI, n
State of North Carolina, hereby certify that rh_rte cofl,nail1 appeared
personally before me this day and being duly sworn acknowled ed that the above form was executed by him.
Witness my hand and notarial seal. this Z0 day of 3LArve , 20 2
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