NCC222284_FRO Submitted_20220622

WAKE COUNTY FINANCIAL. RESPONSIBILITY/OWNERSHIP 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 CAROlINA 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 THE GLEN AT HOLLYBROOK LOTS 49 AND 59
2. Location of land -disturbing activity: Jurisdiction WAKE (Wake Co. or Municipality)
Highway/Street 1320 S Hollybrook Rd Latitude 35.76343 Longitude-78.76343
& Approximate date land -disturbing activity will commence: 7/1 /22
4. Type of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.31
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameCHRIS CUSHENETTE E-mail [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
SMITH EDWARDS, LLC.
919-987-1930
Name(s)
Telephone Fax or E-mail address
2505 WENDELL RD
2505 WENDELL RD
Current Mailing Address
Current Street Address
WENDELL NC 27591
WENDELL NC 27591
City State Zip
City State Zip
S. Deed Book No. BM2022 Page No. 00847 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):
NVR, INC.
[e-mail]
Name
E-mail Address
5734 TRINITY RD, STE 200
5734 TRINITY RD, STE 200
Current Mailing Address
Current Street Address
RALEIGH NC 27607
RALEIGH NC 27607
City State Zip
City State Zip
Telephone[phone]
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;
NIA
Name
NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
(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:
NIA NIA
Name of Registered Agent E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone NIA Fax Number NIA
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.
JOE SCHMIDTKE
Type Ae
name
Signat
VP/ DIVISION MANAGER
Title or Authority
s�3r�zz
Date
I,AL-ICr 7 Z, a Notary Public of the County of �) �✓ "
State of North Carolina, hereby certify that �[J� ��1/yJ�C���� 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 oftv
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Notary
N/01NE S. LEWIS
NOTARY PUBLiG M commission expires L
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NORTH CAROLINA
MMISSION EXPIRES 1017'+2023