NCC221743_FRO Submitted_20220505

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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
Parker Residence
1. Project Name
Z Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
1109 Oakman Ridge Court 36.04049-78.62790
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: 04/01/2022
4 Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas), ao
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Vaibhav Jain (VJ) E-mail [e-mail]
Telephone Cell # 919-633-0681 Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Micheal and Tiffany Parker [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
1008 Foothiills Trail 1008 Foothills Trail
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State Zip City State Zip
018487 00611
8. Deed Book No Page No. 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):
Shail Building Corp [e-mail]
Name E-mail Address
114 Tealight Lane 2841 Plaza Place
Current Mailing Address Current Street Address
Cary NC 27513 Raleigh NC 27612
City State Zip City State Zip
919-633-0681 919-633-0681
Telephone 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
Telephone
State Zip City
Fax Number
State Zip
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.
Vaibhav Jain Owner
Type or print name
Signature
Title or Authority
03/14/2022
Date
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State of North Carolina, hereby certify that kI br 1(.y appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him
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