NCC222609_FRO Submitted_20220725

lw�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=7 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 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.
1. Project Name Lot 10 The Barony
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street1424 Barony Lake Way Latitude 35.959620 Longitude -78.684000
3. Approximate date land -disturbing activity will commence: 6/15/22
4. Type of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreaoe disturbed or uncovered (including off -site utilities and borrow/waste
areas):_
lI
7
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ricky Dickson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
[e-mail]
Fax or E-mail address
27703
Zip
8. Deed Book No. 018913 Page No. 02367 Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Tania and Channing Richardson 919-434-6988
Name(s) Telephone
126 Pepperwood Way 126 Pepperwood Way
Current Mailing Address Current Street Address
Durham NC 27703 Durham NC
City State Zip City State
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):
Monterey Bay Homes, LLC [e-mail]
Name E-mail Address
8801 Westgate Park Drive, Suite 106 8801 Westgate Park Drive, Suite 106
Current Mailing Address Current Street Address
Raleigh NC 27617 Raleigh NC 27617
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:
Monterey Bay Homes, LLC
Name
8801 Westgate Park Drive, Suite 106
Current Mailing Address
Raleigh
City
Telephone,
NC
State
919-277-9921
[e-mail]
E-mail Address
8801 Westgate Park Drive, Suite 106
Current Street Address
27617 Raleigh NC 27611
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
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
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 o rint name
d'� 'i�� I 4L'P"_
Signatu
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Title or Authority
.-It idZZ
Date
I� _J la L�� , a Notary Public of the County of t6
State of North Carolina hereby certify that Ch n Y n �ori aa oAaP" eare
personally before me this day and being duly sworn acknowl4dged that the above form was executed by him.
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Witness "9faVd a3� gtarial seal, this (_day of _ , 20�2 _
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