NCC243034_FRO Submitted_20241001

WPM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No pc cn may initiate any land-disturbing actrvity on one or more aCre�us covered by the Wake
ECounty Unified Development Ordinance before trus form and an acceptable erosion and
COUNTY
sedimentation control plan have been completed and approved by Wake County Department of
�1(�a�><1.,,� Environmental Services, Water Quality }vision- (Please type or print and, if the question rs not
i - appi bie, place N/A in the tank.)
Part A r
1_ ?roject Name 1_4Q 1 tk.)pAc> ci
2. Location of;and-disturbing activity: Juris&tion L0[1 K e ) (Wake Co_ or Municipality)
H,ghway1Street'-U e,i i�1:,i P,,-yi 1,'at Li Latitude'35.9 c `3 Li 5? Longitude — '0• ��'�40-1
3_ A.pproximate date land-disturbing activity will commence: q 7 - 9 L i
4 Type of development(residential, commercial, industrial, institutional, etc.): re s;Af,\- ,-k_1
5 Total acreage disturbed or uncovered i including off-site utilities and borrow/waste
areas): A 1 a
6. Person to contact Should erosion and sediment contra issues arise during land-disturbing acttvity_
Name 1 cLf1 10b k rt E-mail Address- -icon Q. \.0.6 r h.1i WA.9 .&?(l'1
Telephone CA 1 II- G g-()C'7 Cell# Fax#
I. Landownerl.$)of Record(attach accompanied page to Ist additional owners).
'''r6h i n � CiV 21-r-LIB {t r n.ol A4 L'.0 a l CI- l22,-7 C57
Name(s) Telephone Fax or E-mail address
1G-41 OnAln; Dr IC,91 (`n t\\fle-lOr
Current Mailing Address Current Street Address
lRa�rkh t��C 09 1ali-r' 4, tvc: 3 ) q
City State Zip City State Zip
B. Deed Book No 1 CI to Q3 Page No. CI C Provide a copy of the:most current Geed.
Part B.
1. Person(s) or firms) who are tlnanoraliy resporsibie `c: the rxi-disturbing ac1vity (Provide a
comprehensive list of all responsible parties on an attached sheet Include requested information):
-C.'1_r, ( AC - \C (- �J ( C `&-ion. ) \-o -:i fl\im 'Ain/ . ca(
Name E-mail Address
C\ l`r\\ r 1001 C 11kr-I -)r
Current Mailing Address Current Street Address
1Z GA-T; c.'cN t 7 lcc,Ci cl lt1-f i c41 K,C a) b o n
City J State Zip City a Sate Zip
Telephone r�'C1 - Lt .4 4 -1('`�7 Fax Number

2. (a) if the Finandally 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 (RE of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance andlor Land
Disturbance Permit
Name E-mail Address
Current Mailing Address Current Stream Address
City State Zip City State Zip
Telephone Fax Number
(b) lithe Financially Responsible Party is a Partne`shio 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 c1 the Regs:ered Agent
0 r\ -ht r1 r':�( ;,'.Lr �•-Cab\r\Dcj t (cl (r , • COCO
Name of Registered Agent E-mail Address
1l_.'rc\• -.1 1' 4-'.`� - '.-' N e '1 N (-
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone CI \el ` 703 7 Fax Number
The above information is true and corm 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.
�`�i 1 ;"� ire i �10.n •tr g brier rrJCt\tF r
Type or print name Title or Authoy
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Signature Date
I. Fl-,1bra ,(*h + ' icil\ey P-i..Yliii-p a Notary Public of the County of tis;- rP.4. in
State of North Carolina, hereby certify that _ _b � Cc_i1 , OA;; r- 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, tuts '�t 4rhday of A.s.coembpr , 2o.:Q'-i
Dai)ex\als,Al 0A(.1 r8.L .i--imi:L-7,.
�t,: r�,p: Notary
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My common expires
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