NCC242233_FRO Submitted_20240731

* 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 pian have been completed and approved by Wake County Department of
NORTH CAIWLiNq 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 Ammons Acres Logging Plan
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Hwy 97 Latitude 35°48'60" N Longitude 78°21`60"W
3. Approximate date land-disturbing activity will commence: Summer 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):80.0
6, Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tanya Matzen E-mail Address tanya.matzen@brookfieldpropertiesd6
Telephone[phone] Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
NB Ammon Acres, LLC [phone]
Name(s) Telephone Fax or E-mail address
3200 Park Center Drive, Suite 1000 Same as Mailing Address
Current Mailing Address Current Street Address
Costa Mesa CA 92626
City State Zip City State Zip
8, Deed Book No.See attached Page No,See attached 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):
NB Ammons Acres LLC [e-mail]
Name E-mail Address
3200 Park Center Drive, Suite 1000 Same as Mailing Address
Current Mailing Address Current Street Address
Costa Mesa CA 92626
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:
Corporation Service Company [e-mail]
Name E-mail Address
2626 Glenwood Ave, Ste 550 2626 Glenwood Ave, Ste 550
Current Mailing Address Current Street Address
Raleigh NC Raleigh NC 27ic
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
Tanya Matzen ( '
Type or print name ,i Title or Authority
7LI
/ I
Signature / Date
I, GO C\\e Torte PCIAN)Q c , a Notary Public of the County of i ockK
State of North Carolina, hereby certify that TQf> G 1J1Q\ 1 appeared
personally before me this day and being duly sworn acknow edged that the above form was executed by him.
Witness my hand and notarial seal, this4-kin day of al.A.\.I , 20').1-k
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