NCC243202_FRO Submitted_20241016

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 i Development co be ibsi
COUNTY sedimentationUnif ed controlev planlopmen haveOrdinan been completedefor and th s approvedform byand an Wake Countyaccepta le Department ofand
NORTH CARD N,� 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 Marshburn Manor Force Main
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Marshburn Road Latitude 35°48'41.55"N Longitude 78°22'25.70"W
3. Approximate date land-disturbing activity will commence: September 2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Force Main Utility Installation
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 4
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeremy Keeny, PE, PLS E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Meritage Homes of The Carolinas, INC
Name(s) Telephone Fax or E-mail address
8800 East Raintree, Suite 300 8800 East Raintree. Suite 300
Current Mailing Address Current Street Address
Scottsdale AZ 85260 Scottsdale AZ 85260
City 2972 State Zip City State Zip
912-913
7341 664-665
8. Deed Book No. 7341 Page No.672.673 Provide a copy of the most current deed.
9828 898-901
Pact B. 16991 1119-11120
19421 1838-1845
19459 1593-1600.
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):
Meritage Homes of The Carolinas, INC [e-mail]
Name E-mail Address
8800 East Raintree, Suite 300
Current Mailing Address Current Street Address
Scottsdale AZ 85260
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:
Scott Roylance [e-mail]
Name E-mail Address
3300 Paramounty Parkway, Suite 120 3300 Paramounty Parkway, Suite 120
Current Mailing Address Current Street Address
Morrisville NC 27560 Morrisville NC 27560
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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 500 2626 Glenwood Avenue, Suite 500
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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.
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�- i2 sr oft Presldi..i
Type print name Title or Authority
tot o9 /ao (--1
Si ature Date
I, I rQC( ' W) roYL , a Notary Public of the County of (,JGLr'L2.-
State of North Carolina, hereby certify that � appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal, this day of oao , 20 oZ�
No ary
Seal
My commission expires / -I( I
TRACI A. DOIRON
NOTARY PUBLIC
Wake County, North ar ina
My Commission Expires/o) /9 avapj