NCC220508_FRO Submitted_20220126

INW. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=l SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKE
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
�Ri�{ ea���i@�A 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 fill.
t6 P? ll. i�n-,-7e n
2. Location of land -disturbing activity: /Jurisdiction ke (Wake Co
Highway/Street Latitude Longitude
or Municipality)
3. Approximate date land -disturbing activity will commence: `�r-.� ri 064 ✓ © ,Z �-
4. Type of development (residential, commercial, industrial, institutional, etc.): ka;1 de-111 I
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): a C/ Ef- / '2-
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name /u E-mail Address
Telephone Cell # �l J gc�� ..0 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
LIB e.s, d- ��ScS /7 f���i✓G- / f ! 1990 E R / J (✓� / ©(A1t aC/� �c f, . Cv.�
Name(s) Telephone Fax or E-mail address
Current Mailing Address Current Street Address
City State Zip City r-� State Zip
8. Deed Book No. %g/ 8- Page No. _?_ & / 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
comprehensive list of all responsible parties on an attached sheet. Include requested information): e/
Name ,[ E-mail Address -/
l 2 � /,NH vc lc�s� �� c�g �� C� � l � iS �,r�•�T�,r 7'S ,�/C G.,.
Current Mailing Address Current Streeet Address
X.(," Z /�
City State Zip City 1j State Zip
Telephone 9/ c/ ego cog/s 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
Telephone
E-mail Address
Current Street Address
State Zip 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
Telephone,
E-mail Address
Current Street Address
State Zip 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.
Type f print name `
Signature
U c.c} n C� )--
Title or Authority
2-o -,-?e of
Date
I, �auXWiuV+ — t� : bq V L40 2 a Notary Public of the County of jj aka -
State of North Carolina, hereby certify that dh&rl}BS _\Y • appeared
personally before me this day and being duly sworn acknowledged that M above form was executed by him.
Witness my hand and notarial seal, this _day of 0eCeWVVZ4-" 20�_
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