NCC243753_FRO Submitted_20241210

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
WAKECounty 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
HOR,t1 \�« �� 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 6rM i //'gtitikvid5 2 y/
2. Location of land-disturbing activity: Jurisdiction 1,1 Lc, CO (Wake Co. or Municipality)
Highway/Street 11i?c �Lane, Latitude 5/,',O /3PO Longitude 7 s2o 3 2
3. Approximate date/land-disturbing activity will commence: 79/10U ZOZ4/
4. Type of development(residential, commercial, industrial, institutional, etc.): 494-1-11
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): / Z g
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 0.7) �,/6,70 E-mail Address b4-re,..10 tiCXG ,id hg,G
Telephone 9/9- L/ 9 -D 9 9/ Cell# 9/.9-7/. 0 7%L/ Fax# /U`/�
7. Landowner(s)of Record (attach accompanied page to list additional owners):
X1' e Aiiiy/try 11�4 - r G-G( Ol/ /-6?/0-63i) -Cdo,-✓,,Q CkeicriL,,>'4'a S. ` h./..%
Name(s) J / Telephone Fax or E-mail address
Current Mailing Address Current Street Address
eilll k /0 V-bD1 4i,,, h /l/G -774'Pq
City State Zip City I State Zip
8. Deed Book No. o/q-/2 Page No.02 259-0,?7.y 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):
�C Si�' ,,/,,,,),, /./....6Hn,a eP1fP,li11,/rair� �vvr
Name E-mail Address
92e;4 ?ci' Dc. skso w ,e, ,r/� A 5;e57)
Current Willing Address Current Street Address
Abf h /Uc Z, ,6�9A ,C 0 7
City / State Zip City / State Zip
Telephone q/9-6/ 5 / Fax Number 4//11

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 A dress
Current ailing Address Current°Street Address
1 Cy State Zip
4
City fl--
tate P Y
Telephone Fax 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:
410c yoc-r a os+6 e)c ei-e/bm i di7 co -t
Name of Registered Agent E-mail rtddress
(/00 6 c-Ari 6Id Pr 5 D 900 c1 e ld A s-) S'<)
Current Mailifig Address Current Street Addrest
fmle(q h /tJG 2�1na$ 411el9 h N State 2�zip 3
City / State Zip City
Telephone 9/q— 55.— 66 G� 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.
Type or pn a e Title or Ayf
Yp o
, /', /l ?-le
ure Date
/4h tl ,U tJ.. 1•[mili"' , a Notary Public of the County of V v a r 6 e
State of North Carolina, hereby certify that /4 te/X /0,0-- appeared
personally before me this day and being duly worn acknowledged
_that the above
form was executed by him.
1
Witness my hand and notarial seal,this ' day of Otll OR , 20 1T '1
ANDREW J.HURST
NOTARY PUBLIC IF Wake County - 1 �/1
North Carolina Notary v
My Commidiaind Expires July 4,2027 ( �,o a,�
My commission expires f