NCC242702_FRO Submitted_20240903

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
County Development dinance bib
COUNTY sedimentationUnified controlev planlopmen haveOr been completedefore and th s approvedform byand an Wake Countyaccepta le Departmenterosion ofand
,,;.TH 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 Sorrell Pointe Lot 5
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Old Sorrell Rd Latitude35° 41°MIN 21 Sec N Longitude 78° 42° MIN 44 Sec W
3. Approximate date land-disturbing activity will commence: 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): 0.873
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Mathena E-mail [e-mail]
Telephone [phone] Cell# 919-616-9534 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Michael Laboda 440-832-0786
Name(s) Telephone Fax or E-mail address
9042 Red Oak Blvd. 9042 Red Oak Blvd.
Current Mailing Address Current Street Address
Nashville, NC 27856 Nashville, NC 27856
City State Zip City State Zip
8. Deed Book No. 19424 Page No.2443 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):
Blue Heron Signature Homes [e-mail]
Name E-mail Address
4515 Falls of Neuse Rd. 4515 Falls of Neuse Rd.
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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, give name and street address of the Registered Agent:
Mark MacDonald [e-mail]
Name of Registered Agent E-mail Address
4515 Falls of Neuse Rd. 4515 Falls of Neuse Rd.
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
Mark MacDonald CEO
Type or in am Title or Authorit
.1a2 04 A f
Signature Date
I, 1 )qt c ; 5 S14 0.5 , a Notary Public of the County of Wg Ott
State of North Carolina, hereby certify that M f K- M`t C. n ein s 16 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 2 L day of A(A5 IA S} , 20 Z -1
Notary
Seal
My commission expires 0 S/0 I La L a
DARRIS SUGGS
Notary Public
Wake Co., North Carolina
My Commission Expires Aug.3,2028