NCC221030_FRO Submitted_20220323

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the 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
NORTH f ARMINA 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 Pearl Street Townhornes
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Pearl Street Latitude 35.7080 Longitude -78.6092
3. Approximate date land -disturbing activity will commence: TG—+g7 y
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acres a disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2.E
6_ Person to contact should erosion and sediment control issues arise during land -disturbing activity;
Name iiJt LAkM WA-r*ln)S E-mail Address TNwe' 14M LbA
Telephonefft_623 - 43 qq Cell # 3ol- 535 - 0 _�-S Fax # 3C 0 7
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Pearl Street, LLC
Name(s)
PO Box 133
Current Mailing Address
919-795-4287
Telephone
Same
Current Street Address
[e-mail]
Fax or E-mail address
Clayton, NC 27528 Same
City State Zip City State Zip
8. Deed Book No. 011173 Page No. 01388 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):
Name E-mail Address
I I& I GO PAAGTti &J 5 Apk5
Current Mailing Address Current Street Address
City State; Zip City State Zip
Telephone D i - ! 35 - 6R 2 5 Fax Number 31) 1 - 00 ?sl ` b9 6

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:
bmit A) 0(_1V_ bye- e"e, AF- 4©me_s, coM
Name of Registered Agent iuk% 100 E-mail Address
$$D ( W!2 FA-ily. TOAC -�OMe
Current Mailing Address Current Street Address
1.F✓ (�t� Nc- n 6(1 5AA'
City State Zip City State Zip
Telephone 33to 20q -746 5 Fax Number. -_ �q - 1-1-7_ 4B Z-7,
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 attomey-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 or print name
Lz&&
Signature
Title or Authority
Iz-1-Z�
Date
l �h tq,r ( [ocYGrO(=t , a Notary Public of the County of (3 ul ) 1~o rd
State of North Carolina, hereby certify that 121Ck-_-L!11'e5 _ _ _ _ _ appeared
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. 151- day of 1)2cPYn 2d , 20 .21
Nota
Seal �
My commission expires, 1 l 1 ga) 20;t 3
Thurl Cockcroft
Notary Public
Guilford County, NC