Loading...
HomeMy WebLinkAboutNCC220623_FRO Submitted_20220211M�w 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 W� 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 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 The Meadows at Hollybrook - Phase III 2. Location of land -disturbing activity: Jurisdiction Town of Wendell Highway/Street S. Hollybrook Rd. Latitude 35d45'51 "N (Wake Co. or Municipality) Longitude 78d21'35"W 3. Approximate date land -disturbing activity will commence: 04/2022 4. Type of development (residential, commercial, industrial, institutional, etc.). residential 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas):18.0 6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Fred Smith E-mail Address fjsj@fredsmithcompany.com Telephone 919-422-4092 Cell # Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): Smith -Edwards, LLC Name(s) 2102 Pritchard Road Current Mailing Address Clayton, NC 27527 City 8. Deed Book No. 012538 Part B. State Zip Telephone Fax or E-mail address 2102 Pritchard Road Current Street Address Clayton, NC 27527 City State Zip Page No. 01623 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): Fred Smith fjsj@fredsmithcompany.com Name 2102 Pritchard Road Current Mailing Address Clayton, NC 27527 City State Zip E-mail Address 2102 Pritchard Road Current Street Address Clayton, NC 27527 City State Zip Telephone 919-422-4092 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 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: 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. fi .E 0 Type or p4nt name Title or Autho R y Signafture Dat I, St X_.,D, U a Notary Public of the County of-37c ins%s- State of North Carolina, hereby certify thatappeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this t,T"day of (�cxlf'�v^�"�2 , 20 1 Seal C7 U �3 My commission expires