NCC222550_FRO Submitted_20220715

13�w WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
P=41 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.
1. Project Name Spaeder Residence
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
5209 Jeanne Street
Highway/StreetLatitude 36-980 Longitude -78.471
3. Approximate date land -disturbing activity will commence: July 5, 2022
4 Type of development (residential, commercial, industrial, institutional, etc.): Single family residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2.21 acre
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brett Burnette E-mail Address [e-mail]
Telephone Cell # 919 830 4650 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Jeffery & Gwyneth Spaeder 919 308 8741
Name(s) Telephone Fax or E-mail address
724 Reserve Estates Same
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State
Deed Book No, 018052
Zip City
Page No. 749
State
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)-
Rufty Homes, Inc. [e-mail]; [e-mail]
Name E-mail Address
PO Box 5426 5121 Kingdom Way Suite 208
Current Mailing Address
Cary NC
City State
Telephone [phone]
Current Street Address
27512 Raleigh
Zip
NC 27607
City State
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone 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.
Type r pri t name Title or Authority
a_'�,j,Lc' 5
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Signature 0 Date
I, /'had '�i. Se.rcc a Notary Public of the County of _Wake
State of North Carolina, hereby certify that KeRN appeared
personally before me this day and being duly sworn ackno ledged that the above form was executed by him.
Witness my hand and notarial seal, this 19 day of 20.2�2
ary
My commission expires 1 a a0a5