NCC250171_FRO Submitted_20250206

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
WAKEr, County 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 cnrc,e.€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 Lot 7 Bold Run Hill Road
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Bold Run Hill Road Latitude 36.035309 Longitude -78.590464
3. Approximate date land-disturbing activity will commence: January 1,2025
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): O 7
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Norman S.Dillard,III E-mail Address [e-mail]
Telephone Cell# 919-369-4128 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
NSD III Holdings,LLC 919-369-4128 [e-mail]
Name(s) Telephone Fax or E-mail address
14112 Bold Run Hill Road 14112 Bold Run Hill Road
Current Mailing Address Current Street Address
Wake Forest,NC 27587 Wake Forest,NC 27587
City State Zip City State Zip
8. Deed Book No. 19600 Page No. 2469-2471 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):
PAKT Construction,Inc. [e-mail]
Name E-mail Address
14112 Bold Run Hill Road 14112 Bold Run Hill Road
Current Mailing Address Current Street Address
Wake Forest,NC 27587 Wake Forest,NC 27587
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:
N/A
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:
Norman S.Dillard,Ill paktconstructionagmail.com
Name of Registered Agent E-mail Address
14112 Bold Run Hill Road 14112 Bold Run Hill Road
Current Mailing Address Current Street Address
Wake Forest,NC 27587 Wake Forest,NC 27587
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.
Norman 5.Dillard,III Owner
Type o print name Title or Authority
Signature Date
I, Wendy Ann Dyer , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Norman S.Dillard,Ill appeared
personally before me this day and being duly sworn owledged that the above form was executed by him.
Witness my hand and notarial seal,this // il day of ' F --f -i-- , 20 --`-
(i _t_t:' JAL" )_...11.-tt,c -2.--)17.,_..0
ndy Ann Nota y
Wendy
PUBLICDyer
Wake County, N.C. My commission expires /0 crj c,;ZS'