NCC221418_FRO Submitted_20220412

WAKE COUNTY FINANCIAL RESPONSIBILITY'IOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No 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
NURIH CAPOLINA 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 (dame laDg GJe l ck Rae) .l: r.
2. Location of land -disturbing activity: Jurisdiction _ _ �3AJ& (Wake Co. or Municipality)
Highway/Street4p_Jr_4. �. _ Latitude_, .35. 11S ;2 Longitude
3. Approximate date land -disturbing activity will commence: a-1❑ rMI-4-a.
4. Type of development (residential, commercial, industrial, institutional, etc.):i
S. Total acreage disturbed or uncovered (including off --site utilities and borrow/waste
areas):_ /. o-7
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam e�1—ml � E-mail Address ��rAf2, lags "�m-z-n�
Telephone — /N/4 Cell # ftg Fax #l: A,/A
7. Landowner(s) of Record {attach accompanied page to list additional owners}:
Names)Telephone Fa or E-ma" address
Current Mailing Address
RleiAc' nI C
City T State Zap
/VR —
Current Street Address
N14
City State Zip
8. Deed Book No. 1 Page No. e��? _ Provide a copy of the most current deed.
Part B.
1. 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):
Name �' E-mail Address
Iln RA aL- J 1fause- U sae-ka N�
Current Mailing Address Current Street Address
1&0^ tA' &lip id AZA
City J vIF101 Zip City State Zip
Telephoned`i - Z�%'1-gag Fax Number AIA

2. (a) if the Financially Responsible Parry 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 Sedimentafion Control Ordinance and/or Land
Disturbance Permit:
/V/_` _. -- - &
Name E-mail Address
J�t/ A /VA
Current Mailing Address Current Street Address
-- nZA N A _
City State Zip City State Zip
Telephone /V A Fax Number _ V A
(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:
A)A- AjA
Name of Registered Agent E-mail Address
X A/A
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone / A Fax Number A/A _
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 prhtname Title or Authority
n ffure Date
-----------------------------------------
1, A4V a Notary Public of the County of
State of North Carolina, hereby certify that ���.• _ �� S9t appeared
personally before me this day and being duly swom acknowled ed that tfi e- a ove form was executed by him.
Z
Witness my hand and notarial seal, this day of .20
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- My commission expires
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