NCC222459_FRO Submitted_20220708

'i: A" ` WAKE COUNTY FINANCIAL, RESPONSIIBILITYIOWNERSHIP FORM
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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
NORTel cknoL,rrn Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.+l + -
I. Project Name 't' lD G� t"1 Pa I �?- L nT a
2. Location of land -disturbing activity: Jurisdiction WG+ (Wake Co. or Municipality)
Highway/Street ff0(0<-,rr -4k Latitude 35, 38M Longitude
3. Approximate date land -disturbing activity will commence: 7- Z [4 • Z- 2 —
4. Type of development (residential, commercial, industrial, institutional, etc.): 'i.a St dU 0_� t C­
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): qL__3_�e 9 .
6. Person to contact should erosion andsedimentcontrol issues arise during land -disturbing activity.
Name s-I L P i� pro I ^ E-mail Address --F "()'o E � � rp-o -L0 ►W'- J X
Telephone Cell #.9 1 1.}+ �l(� �j 3 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
4L -hrc)ce 5 0 rV-0,0
Name(s) I()
1 �'t�
Current Mailing Address
P—m I _P( XL'
City State Zip
9!mil, gc4q `IZ80
Telephone Fax or E-mail address
Current Street Address
City
State
Zip
Deed Book No.. Jelgo Page No. Provide a copy of the most current deed.
Part E.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehonsive list of all responsible parties on an attached sheet. Include requested information):.
'e (-
Name E-mail Ac1dress
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone l�7. A��U'�2��� 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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
The above information is true and correct to the Kest 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 h ein.
�e r r Lk_) k c I -if C' .
Type or print name Title or Authority
4Z i /2z
5i re Date
I� ..J�LC'CZ !`.� �� rf�On , a Notary Public of the County of _if{�C�_rY�
State of North Carolina, hereby certify that _, _ -W-) appeared
personally before me this day and being duly sworn acknowlddhed that the above form was executed by him.
Witness my hand and notarial seal, this 1
Seal
JESSICA D HUDSON
NOTARY PUBLIC
DURHAM COUNTY, NC
My Commission Expire _W__<' a__Z-1
day of Jwna 20
N ary
My commission expires