NCC221826_FRO Submitted_20220518

I 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
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 C:AROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Project Name Perry Farms Phase 3 Lots 94,95,96,97,98,99,100,101
2. Location of land -disturbing activity: Jurisdiction Wake Co
Highway/Street Bottom of Page Latitude 35.95
3.
4
(Wake Co. or Municipality)
Longitude -78.46
Approximate date land -disturbing activity will commence: 1 /20/2022
Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acrPanP disturbed or uncovered (including off -site utilities and borrow/waste
areas): 3.3
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Landry Wood E-mail Address [e-mail]
7
8
Telephone [phone]
Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Cambridge Classic Homes LLC 919-562-5751
Name(s) Telephone
2519 Village Manor Way
Current Mailing Address Current Street Address
Raleigh NC 27614
City State Zip City
Deed Book No. BM2021 Page No. 01363
State
Fax or E-mail address
Zip
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):
Cambridge Classic Homes LLC
Name E-mail Address
Current Mailing Address
City
Telephone.
State
Zip
Current Street Address
City State Zip
Fax Number
105,109,113,117,121,116,112,108 Nate Court, Wake Forest 27587

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
Telephone.
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
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.
Keith Wood
nature
Builder/Owner
Title or Authority
Date
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I , a Notary Public of the County of 1,/ 6
State of ,North Carolina, hereby certify that k"i od 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 5 day of JG� , 20
Amy L Warren _.__
NOTARY PUBLIC Notary
Seawake County, NC
My Commission Expires February 2, 2023 My commission expires