NCC243470_FRO Submitted_20241112

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any Isnd4bturbng acbvgy on.a mae acres as covered by the Wake
County lhrlied Development Ordinance baby. this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
....11.1.U.,.. EnMronmsn ei Services,Water Quality Division (Please typo or print and.If the questlon is not
appaoebbs.piece WA In the blank.)
Part A .
1. Project Name l- 6.1 14
2. Location of kind-disturbing activity. Jurisdiction IAA;4£ (Wake Co.or Municipality)
Highway/Street 12.13 wC s41.tatb de 1, 11`1PA Longitude - 7$ .C 81$ J
3- Approximate date land-disturbing activity will commence 7//Y/2 2 1 4. Type of development(residential,commercial,industrial.rnstitubonal.etc.). r-e 'Qt. j4 a(
5. Total scream disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.85
6. Person to contact should erosion and sediment control issues arise dung land-disturbing activity.
SIName C 1 J rh C 14f" E-mad Address 511-(.:r 4ad)0-"4" 24�Or Y� 4,4o„s.
Telephone it PI-) J ( '�' )I Cell a Fax I
-11
7. Landownerts)of Record(attach accompanied page to list additional owners):
brn4r^ --a Ail;s4 k Li4 1 s.,ks 1IH -5-2 - , 3S0rip r6 'fJ uM
Names) Telephone Fax or E-mall address
S301 w;ncti�" U'zf.. I f)o1 w/,.,(�� Lam.,,,,
Current Mailing Address Current Street Address
f...(fryC Nce 27(91S / ayi All, a76/5-
City Stab Zip City 7 State ZIP
8. Deed Book No. 1 1 3 G 1 Page No. 2$'�] Provide a copy of the most current deed.
Part B.
t, Person(s) or firms) who we financially responsible for the land-disturbing activity (Provide a
comSpprehensive list of all responsibleparties on an attached sheet.Include requested information)
Cot.ji Mt - �
i r"`,L 14ir�)� � low�C4lfP*4/1,
Name E-mail Address
1(916/ Ain(Gn Kit ILO aLik R�
Current Mailing Address Current Street Address
k 4 14.4 E-44,4 , A/C- 744
City State Zip City State ZIP
a
Telephone 1 m 'S-r1 -1011 Fax Number

2. (a)tf 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-med 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 engagrng in business under an
assumed name attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation,grve name and street address of the Registered Agent
B
SaL/*ud 5t.U+Jr 7- SI- r' `)t't'i..r/'✓n,jtcrywj_C gry ll.Glyn
Name of Registered Agent E-mad Address
6 I i Lc.‘Gr, /' 16 141 0494lr 11^ gel
Current Mailing Address Current Street Address
1 .) iyk N( i2-7 t414,1 itr( °-7 (lag
City State Zip City State Zip 4
Telephone "I/q - 511 ',b 67 t 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 heron.
Type or print name Title or Authority
AJ .A... -a U21 / 2L
Signature Date
lSktieAft314NaL._
l /i , a Notary Public of - County of V
State of North Carolina. hereby certify that l b1/?. Q1X ed
personally before me this day and being duty$ ackn• -•,=d ffffiita►I the above form was executed by him.
f1
Witness my hand and notarial poI1,lhis ai day of v x
'�E O '
I �`�P�..;4 i A R y�,y Notary
Seal .13P• U •_ '"t 42//J9 ', G - t'T. My commission exdres
calk: