NCC220082_FRO Submitted_20220106

sow WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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
(1 t 1 N 1-Y sedimentation control plan have been completed and approved by Wake County Department of
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 HUSh Bo fn °
2. Location of land -disturbing activity: Jurisdiction Vv L (Wake Co. or Municipality)
Highway/Street _fVf fILatitude_ : � .ri Longitude — , Ly -7
3. Approximate date land -disturbing activity will commence: I /0 1
4. Type of development (residential, commercial, industrial, institutional, etc.): E2 Id�,fl
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ 3 y
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: /
Name C. p QA E-mail Address _orm,kI ® ouf hu, 1?15a ro M
Telephone -I G� o ' C'o �% Ce11 # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
hmc'n► C ,
Name(s)
7-116 TuscL-e, �� J� e 0 d -
Current Mailing Address
City State Zip
ql�"z1S UI1S
Telephone Fax or E-mail address
Current Street Address
City
State
Zip
Deed Book No. Q 17 5 7 5 Page No. 0 17 0 q Provide a copy of the most current deed.
Part B.
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):
kl(' mon') �6r4GCi}0n i i1 C) mnAJc-e"fC'3 fiL,Cr.rl
Name E-mail Address
('4 A)-(- 3r1 15 Jtd S}
Current Mailing Address rr Current Street Address �! r
SO M c. L- 27� ?g o n i p� I IU f r� _ 2_ M 1
City State Zip City State Zip
Telephone C� D D ` G'0_ _. Fax Number

III. GENERAL INFORMATION
1. Property Owner (s) (specify the name of the corporation, individual, etc., who owns the property):
Name: Qr.'r,jc, 14r(s1)
Street Address: �7 71 C .1u 5 <«rt k) Q 2 t r l W0, 4, i1 14C. 7S� l
Mailing Address:
E-Mail Address:
Phone#: (91 � ) 21 - 3 8 1 g Cell#: ( ) Fax#:
2. Applicant* (Person to whom all correspondence will be sent):
Name: I -Co.,r 9, l30,(_s
Firm/other:
Street Address: � 3 65y c . w4)n{,4 91 C. 2. 7S 76
Mailing Address:
E-Mail Address:
Phone#: (�) Cell#: ( ) Fax#: C
Relationship to Owner: 8 ,1; 1 de r
*If not a resident of North Carolina, a North Carolina agent must he designated far the purpose of
receiving correspondences.
IV. APPLIICANT'S CERTIFICATION
PRINT NAME
SIGNATURE
Y RESPONSIBLE
V. FEES
Individual Lot Plan Review Fees
DATE 2
S&E ,0 so — I Acre x $250.00 - 2 5 0 L 0 0
Disturbed acres (to hundredth of acre) round to nearest dollar
Fees prorated
Individual Lot Permit Fees
S&E c� o - ( Aug x $250.00 = '3_5 0• C) o
Disturbed acres (to hundredth of acre) round to nearest dollar
Fees prorated
Fees - invoiced upon application
IF A LOT HAS A STREAM CROSSSING submit DWO.404 and/or 401 approval document
*For flood hazard soils or FEMA crossing, Flood Permit is required - apply to Permit Portal for
Flood Study Permit
Note: apply separately for building permit, well and septic through Permit Portal

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
!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.
Car,rr,
Type or print name Hc,-mm,)
_
Signature
Title or Authority
10 /1.9- / I n 2 1
Date
a Notary Public of the County of
State of North Carolina, hereby certify that0Aappeared
personally before me this day and being duly sworn acknowledge tha# the above form was executed by him.
Witness my hand and notarial seal, this day of , 20 L
&a/jot,,
Notary
� � My commission expires
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