NCC220679_FRO Submitted_20220209

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
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
NORI H CAPOUNA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name 1205 Anna Brook Ln, Raleigh NC
2. Location of land -disturbing activity: Jurisdiction wake (Wake Co. or Municipality)
Highway/Street 1205AnnaBrook Latitude Longitude
3. Approximate date land -disturbing activity will commence: Feb 1, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): one single family ham
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 7S nvrnc
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brad Greene E-mail Address [e-mail]
Telephone [phone] Cell # 919-422-2438 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
HomeQuest Builders Inc 919-422-2438
Name(s) Telephone Fax or E-mail address
303 Grand Ave, Raleigh NC
Current Mailing Address
Raleigh NC, 27603
City State
8. Deed Book No. 18502
Part B.
Zip
Project Address: 1205 Anna Brook Ln
Current Street Address
Raleigh NC 27614
City State Zip
Page No. 2670 Provide a copy of the most current deed.
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):
HomeQuest Builders In
Name
303 Grand Ave
Current Mailing Address
Brad@ homequestnc. com
E-mail Address
303 Grand Ave
Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Telephone.
919-422-2438
Fax Number 919-422-2348

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
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:
N/A
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.
Brad Greene Vice President
Type or print na e
Sig e
Title or Authority
lbll2_0 -2--Z,
Date
I, � jc,_Jon a Notary Public of the County of W
State of North Carolina, hereby certify that r q ch t' appeared
personally before me this day and being duly sworn acknowledg that the above form was executed by him.
Witness my hand and notarial seal, this _day of 20 G2
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