NCC242278_FRO Submitted_20240726

W. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any lend-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
,,,,,,,,,,,,,,,,,,,, Environmental Services,Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
0 / (�-2f?h 0)C /�u'1°r
1. Project Name ' /
2. Location of land-dis rbing activity: Jurisdiction W aet. C.-4' (Wake C r Municipality)
Highway/Street II4eh `2'Cat Jude Longitude
3. Approximate date land-disturbing activity will commence: (0/3V/it/
4. Type of development(residential,commercial, industrial, institutional, etc.): eeciitpthes.
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): . $(ocI
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 03 P p S 4/t E-mail Addres ®;M7/"h L,CD/n
Telephone 41 IcA • 5-Z 1-1-‘,S Cell# Fax#
7. Landowner(s)o Record(attach accompanied page to list additional owners):
ta
e) bl v / 1 ( L 9M.5z4.cSS% ,5-0-0 at inc.I- C°' -
Name(s) Telephone Fax or E-mail address
-PD 0, /Z0e__(-, r L ) .
Current Mailing'less Current Street Address
I ie 41.1 1 kitf 2-75"9( /k)en4/I it)L 7.,7S'
City State Zip City State Zip
)a
8. Deed Book No. 1 1 (03-1 Page No. 15—.S 3 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 li t of all responsible parties on an attached sheet Include requested information):
o /'
n Pool 01/3/-ruvhd„,
- oeiPoietf-iic_. coo,-
Name E-mail Address
(":_vb�a9Q 120 G,.,-- ro.„. &w,
Current Mailing Address Current Street Address
Lii4/1.(U AC , Z-ts&ci (A4, .1I )U - 27sq
City state Zip City State Zip
Telephone q(a • 5-Z`T • 6.5-S ' 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 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,g$Ü) /
ve nameS6 and street address of the Registered Agent:
o5 2 K- O tT(?__Oy eo(✓t h c.., co 1"-`
Name of Registered Agent E-mail Address
12o L.>fi1 IZO 64"--"ropt&Lvi .
Current Mailing Address Current Street Address
(d tAck I I AID Z 79( Li&di 1 AJC 2 7-rel
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.
05-- 5c o M-e wv,�� K.
Type or print Title or Authority
I 8 I '1
Signature Date
I, VA Ocy.e (-Lc ,a Notary Public of the County of L-4'Z..
State of North Carolina, hereby certify that -3.S 14 nk 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 i day of ""� , 20
tk-t":41\
T ••,t�"" Notary1t�Q , 1114111(,)16
_ My commission expires
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