NCC243336_FRO Submitted_20241030

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CPPI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
n Dem O be b
COUNTY sedimentationCountyU ified controlev planlop ent have beenrdinance completedefor and this approvedform byand an Wake Countyaccepta le Department erosion ofand
NORTH C,ROI 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 Prescott Manor Lot 96
2. Location of land-disturbingactivity: JurisdictionCounty Y Wake (Wake Co. or Municipality)
Highway/Street 8208 Mary Claire Lane Latitude l (90 J r 3�- f�� I Longitude V 0
3. Approximate date land-disturbing activity will commence:
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.520
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dan Cunningham E-mail Address [e-mail]
Telephone Cell# 919-427-8982 Fax#
7. Landowner(s) of Record(attach accompanied page to list additional owners):
Brandywine Homes, Inc. 919-427-8982 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 910 732 Reserve Estates Dr.
Current Mailing Address Current Street Address
Wake Forest, NC 27588 Wake Forest, NC 27587
City State Zip City State Zip
8 Deed Book No. 19525 Page No. 2745 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):
Brandywine Homes, Inc. [e-mail]
Name E-mail Address
PO Box 910 732 Reserve Estates Dr.
Current Mailing Address Current Street Address
Wake Forest, NC 27588 Wake Forest, NC 27587
City State Zip City State Zip
Telephone [phone] Fax Number

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4 • A t "....` /••• , I I" ".' '
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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:
41 N/A
Name E-mail Address
Current Mailing Address Current Street Address
r Cit
o y 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:
N/A
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.
Colleen M Cunningham President
Ty e or print nnaame Title or Authority
i k �- gI ' - Iaac-(
Signature Date
l, —T'ctra— 8' , a Notary Public of the County of 0
State of North Carolina, hereby certify that CO I I P-)c-rI al C-M'L&r� appeared
personally before me this day and being duly sworn acknowledged that the above form w executed by him.
Witness my hand and notarial seal, this 1 day of , 20
al& i 4)--UY16
Tara B King ary
NIY PUBLIC
Wake County,NC My commission expires /0 19 e ctl
My Commission Expires October 19,2028
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