NCC221569_FRO Submitted_20220421

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
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 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. cc
1. Project Name ', U 'At Vh''�.0 T ESEIVE
2. Location of land -disturbing activity: Jurisdictionw WE (Wake Co. or Municipality)
-1101
Highway/Streetwo ft LNE Latitude35.9141510
Longitude -It. wA 6'70
3. Approximate date land -disturbing activity will commence: ail 11.1022.
4. Type of development (residential, commercial, industrial, institutional, etc.): VESID"I L
5. Total acreage
areas): 0.80
disturbed or uncovered (including off -site utilities and borrow/waste
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameboVcj toss E-mail Address 00SA OM W AM
Telephone 11q-111- Jill Cell # Ili- Ill 1124 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
MONIEREI tA`i tomes, uL 414-211- gg2-1 p,M1E1.E001 hizttbM(Stem
Name(s) Telephone Fax or E-mail address
01 WM TE PARS. M. an 10�
Current Mailing Address
ME161H _ 214111
City State Zip
%% 11
Current Street Address
U. at
City State Zip
Deed Book No. t11' Page No. 60610 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 a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
MoNirm" M %W01 UL WELfe WNoMES• tom
Name E-mail Address
QM 1N� t8' pt' c�r� SUS lob
Current Mailing Address T� Current Street Address
Maw we t"611A b1c 21103
City State Zip City State Zip
Telephone g14-211- M11 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.
y- 6WNEV%
Type r ri t a _ Title or Authority
Signature Date
------------- ---------------------------------------------------------------------------- -------------------------------------------
lle4— , a Notary Public of the County of 4ke-,
State of North Carolina, hereby certify that t—y1 "'i .S�gw 04 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 _day of 20 22—
,0"' IB�EICy
;�,Q; ARy'�9'�
O ' Notary
xp_
Seal : CoM2 • E
Z ;My7-18- 026 2 My commission expires g (/