NCC243341_FRO Submitted_20241029

WAKE COUNTY FINANCIAL. RESPONS1I3ILI`t`r/OlitINERSHII3 FORIldi
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WACounty 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
NORTH CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
I E1: A.
•
'I. Project Name G'1 _'
2. Location of land-disturbing activity: Jurisdictions IA)«Ice (.0, (Wake Co.
�oriMunicipality)
Highway/StreetO I GAM 't.-i-6f"E-ifitulab 7C:�;,f'( Longitude /?, (Lf t1g3
3. Approximate date land-disturbing activity will commence:
4. Type of development(residential, commercial, industrial, institutional, etc.): Ce`-;; .,„
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): O.S
6. Person to contact should erosion 11and sediment control issues arise during land-disturbing activity:
Name t J btil// k, t/VIi�/ E-mail Address Cam. - ar7 ( LJC1" Sar1, C 0.4.)
Telephone 6714— -0"7`7S Cell# Fax# q/ei^ —C(1/6©,
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Ca:n l-r20. 6�IM Ids LLC _t/C,a -077S- q/q-'164 D
Name(s) Telephone Fax or E-mail address
WO 1:) r ✓ant 1'0," l Ds--
Current Mailing Address Current Street Address
,)c Q75/3
City State Zip City /^��, State Zip
8. Deed Book No.i q L��( I Page No./_7e7—I 1"'� 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):
Name (� c 'E, S
E-mail Address
I Dl�t� t�J�l�lr'I �� /�11 iJl't if P1 �1r. /o Sq _
Current Mailing Address Current Street Address
City J�,'/ State Zip City State
_ /,/ Zip
Telephone(/a `�� —d 77S Fax Number q/ I�t --q'�'/ Ip0

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:
jG((1/La✓i . 1, l:� Ca m4A i,c14.zolcom CO
Name of Registered Agent E-mail Address e�
LLD l tic( ve S . cs �
Current Mailing Addr s Current Street Address
027513
City J State Zip City State Zip
Telephone "r ICJ —Q� Fax Number 4/q t/b ? - ta, 0
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.
6e%rij Gi /1/N ►C w44-40/Oncir-
Type or print name Title or Authority
.t.A1 — 1 -7-
Signature Date
I, Vi'ekie s• ltj a.�s , a Notary Public of the County of Wake-
State of North Carolina, hereby certify that Ben ctrni' k, (,Jared appeared
personally before me this day and being duly sworn acknowledted that the above form was executed by him.
ri-
Witness my ha,.. .tarial seal, this C7 day of Sepkori/x►;202'1
S.ilk
tp
Notary
Sell*
My commission expires 5 1 23/26
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