NCC242267_FRO Submitted_20240806

WWI 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
WAKE
County 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
1 ; ,; AI:()I 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 Lc ,-27/ a t'rI`Y.P
2. Location of land-disturbing activity: Jurisdiction waL2 C 7. (Wake Co. or Municipality)
Highway/Street Hct tl(Y.ep (.Ji4t-atitude Longitude
3. Approximate date land-disturbing activity will commence: 021(0 i 02 3
4. Type of development (residential, commercial, industrial, institutional, etc.): VPSicQP MG,(
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): , t6
6. Person to contact should erosion and sediment control issues arise/during'land-disturbing activity::
Name D Ut!i DO Jacksdn U E-mail Address C)C 1 6 ( C f'f'IGtc `. Car
Telephone Cell# 19-70C 36-7q Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
l)a tit ot J acLsa,-, 6 (c(- 7C--367q C',6 j c d<5 ���c ?,,,,,A, I CO/0
Name(s) Telephone Fax or E-mail address
(0702 Lake WaCkoa Pot?,, C f-n2>
Current Mailing Address Current Street Address
C2dCe._519'=%-r. Aic a75,3y
City State Zip City State Zip
8. Deed Book No. I O�i 0,30 Page No. l a,?ja ! 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):
)avi n{ )aG k92 n d i a O 61 e C ma, .CoY�
Name E-m it Address /
(a702 Lake Pacie.ov . Pat . ,vme
Current Mailing Address Current Street Address
c2l01s1a9 . JUC✓ (,2-753
City State Zip City State Zip
Telephone °11 9` 70C Fax
367 C( 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:
os-e- .erQc 1 broq/ r a H-Pv
1/J, COWL
Name V E-mail Ad r( ss
9051 5+r;cK land ci Q o5 sgrocletnclikti
Current Mailing Address Current Street Address
1-441.e.;)11 NC ;Jos `RcJeh C.
N1(o is
City i/ State Zip City V State Zip
Telephone 919 6 4 ! Li 9 L b cell Fax Number
qiq g4S 3 I a of-Gc
(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.
111U1�'i _ Q_(tc-4 ,,- 4r/v bui(kc r4 6 7( / SPk/
Type or ring e Title of Authority
7/
Signature ( Date
I, 3' .tcL-i Lee , a Notary Public of the County of 1,,L)ayn•e
State of North Carolina, hereby certify that 1t7av-d C. J clkS4 el 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 o4 day of T,744e7 , 20 a3
•
rr` •.�� �kyj•�F,��., Notary
Seal r : -t. s•
A�T'._ - x9/ay
R} = My commission expires
C Va1,C 1 m
%.<Cóic4
;••. 18.2uz 04/
•0