NCC222915_FRO Submitted_20220815

13PTWAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W= No person may initiate any Lv d-disturbing activity on one or more acres as covered by the Wake
WAKIECounty Unified Development Ordinance before this form and an acceptable erosion and
C�71lI! 1 Y sedimentation controi plan nave been completed and approved by Wake County Department of
Environmental Services, Water Quality Division. {Please type or print and. if the question ;s not
applicable. place NIA in the blank)
1 ao �1� TiLA,t~
Part A.
i . PraJeCt Name
fty�GQ It AfTiA: Lol wA V- Gre'4r ac 17q 7
2. Location of !arid -disturbing activity Junsdict;on W A k- (Wake Co. or Municipality)
t1�yt
Highway/Street G ►aT'- Latitude IL, Doc, of Longitude
3 Approximate date land -disturbing activity will commence J�4ar,'�
4 Type of development (residenital, commercial. industrial instituuonat etc.)= Rf }.tr+1r 4 L
S. Total acreage disturbed or uncovered (Inc!uding oft -site utilities and borrow/waste
areas! , I I
S. Parsan to contact should erosion and sedrrnerit Control issues arise during land -disturbing activity.
Name 131u1i , j pA T\" E-mail Address 4 (AV
Telephone Cell # q t Fax #
7. Laridowner(s) of Record (attach accompanied page to list additional owners)
Name(s) UTelephDfie Fax or E-mail addres
[D 11 A C T4 ] rcr�j - • q D&,r2
Curren! Mailing Address
� n vim. " ti a_? s 9_3
City State Zip
SAS A��_+
Current Street Address
City
State
zip
6 Nei Book No. 130 Page No."41 �1: Provide a copy of the most current deed
Part B.
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).
_ Gjra,,j j. j4ti L, l&b LJ_L, 9 2 [ A.� �, ,vt_6 + �� �a AA
Name _j jjV,,d P14TStj E-mail Address
TVA LA &jk wA
Current M allirioU AdLht:aa Cure+.r Street Addroas
L ArA � L, 4-1 � i 3
City G State Zip
a
Telephone I i G 0 �� - '-i
City State
Fax Number cf t 11 - �.T� 70_11
Zip

2. (a) If the Financiatly Responsible Party is not a resident of Wake County, identity a designated agent in
Wake County to receive any notice, process, pleading in any action ar legal proceeding arising out vj any
matter relating to the Wake County Erasion and Sedimentation Control Ordinance and/cr Land
Disturbance Permit:
Name
Currant Mailing Addr'e'sAl
City
Tetephone
State Zip
E-mail Address
Current Street Address
City state Zip
Fax Number
{ra) It 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 E-mail Ad
Current Mailing Address Current Street Address
City �j F State zip
Telephone a I i i 61 )Og `f
City
State Zip
Fax Number '111 3 Y Y )0,11
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) 1 agree to provide
corrected information should there be any change in the information provided herein.
3%JLAts EA I D
Type print name
Signa e
M ftq4Afr'?"-
Title or Authod
Date
I. a Notary Public of the County of.
State of North Carolina, hereby certify that 1+-S}L' � & appeared
personally before me this day and being duly sword ackniowedged that the bbove form was executed by him
Witness my hand and notarial seal. thm 1,1—ciay Of c 24 r
Acfary
Se
CHA1; T 3 S E ,r�,;t� y commission expires% {-j) 1J5y�,
llnrary �' .101t. noorth Ce►iriin
VV*XC ceunir
My Cor►lTI;a9.0t$ c`_x ray
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