NCC220169_FRO Submitted_20220110

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
WAKICounty 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
NORIH CAROLINA 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 15 Alpine Creek
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municioalitvl
Highway/Street 1416 Alpine Creek Dr Latitude
35.9407
3. Approximate date land -disturbing activity will commence:
Longitude-78.6007
12/15/2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential - SFH
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.75 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Sherman E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Bost Construction Company 919-460-1983 info(&bosthomes.com
Name(s) ost ustom Homes Telephone Fax or E-mail address
1941 Evans Rd, Cary, NC 27513 1941 Evans Rd, Cary, NC 27513
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. 0181 --Page No- 00598 Provide a copy of the most curren -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):
Bost Construction Company infoOhosthornes.corn
Name E-mail Address
1941 Evans Rd, Cary, NC 27513 1941 Evans Rd, Cary, NC 27513
Current Mailing Address Current Street Address
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:
Name
Current Mailing Address
City State Zip
Telephone.
E-mail Address
Current Street Address
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Rex Bost
Type -or -print, —
Founder and President of Bost Construction Company
Title or Authorit; — --
1,2 -.2 - :
Signature Date
ala" �r
b ®, a Notary Public f the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn lacknoXwledged-t at the above form was executed by him.
Witness my hand and notarial seal, this
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