NCC242259_FRO Submitted_20240724

OW. 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
I County Unified Development Ordinance before this form and an acceptable erosion and
s WAI I
s COUNTY s sedimentation control plan have been completed and approved by Wake County Department of
I Environmental Services, Water Quality Division. (Please type or print and, if the question is not
E J applicable, place N/A in the blank.)
Part A.
1. Project Name RBPR-124193-2024 (4912 Hidden Pasture Way)
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Hidden Pasture Way Latitude 35.912 Longitude -78.354
3. Approximate date land-disturbing activity will commence: 7/8/2024
4. Type of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1 .525
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dustin Moore E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Colebrooke Custom Homes, LLC [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
848 Cooke Road 848 Cooke Road
Current Mailing Address Current Street Address
Louisburg NC 27549 Louisburg NC 27549
City State Zip City State Zip
8. Deed Book No. 019649 Page No. 02313 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):
Colebrooke Custom Homes, LLC [e-mail]
Name E-mail Address
848 Cooke Road 848 Cooke Road
Current Mailing Address Current Street Address
Louisburg NC 27549 Louisburg NC 27549
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:
Joseph John [e-mail]
Name E-mail Address
143 Wait Avenue 143 Wait Avenue
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
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:
Dustin Tyler Moore [e-mail]
Name of Registered Agent E-mail Address
848 Cooke Road 848 Cooke Road
Current Mailing Address Current Street Address
Louisburg NC 27549 Louisburg NC 27549
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.
Dustin Tyler Moore Owner/General Contractor
Type or print name Title or Authority
p,,,,,...„- --/1,,,,-- 7/2/2024
Signature Date
1,L_��)o n n H�k--- , a Notary Public of the County of G,C.2
State of North Carolina, hereby certify that Esc-i,'\ i - Oo;-e-- 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 day ofe i , 20
Wendy Ann Dyer Notary�,� I���— L/ e,2..-
NOTARY PUBLIC
s v al Wake County, Myexpires0- q c e-
N.C.� � commission