NCC222914_FRO Submitted_20220815

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty 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 N/A in the blank.)
Part A.
1. Project Name_ Kiger Residence
2. Location of land -disturbing activity: Jurisdiction wake County (Wake Co. or Municipality)
Highway/Street 4000 Jaback Drive Latitude Longitude
3. Approximate date land -disturbing activity will commence: Completed in April 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.96
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Kiger E-mail Address [e-mail]
Telephone_ 919-830-1171 Cell # Fax #
919-830-1171 N/A
-- ___.------.-----__.._
7
Landowner(s) of Record (attach accompanied page to list additional owners):
Jonathan and Cynthia Kiger 919-830-1171
Names) Telephone
324 Rustling Way same
Current Mailing Address
Zebulon NC 27597
City
8. Deed Book No
State
Current Street Address
Zip City
State
[e-mail]
Fax or E-mail address
0
Page No. — 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):
Landowner -self
......... .......... ...... ...... .... ......... .................... ..................... ........ ....
Name E-mail Address
Current Mailing Address
City
Current Street Address
State Zip City
Telephone Fax Number
State
ME

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:
N/A
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone — 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:
N/A
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.
Scott Kiger Owner
Type or print name % Title or Authority
06-28-2022
ignature Date
'zp�c-t'+A`QY -5 j f.\ tit (L a Notary Public of the County of huQ VAS
State of North Carolina, hereby certify that j G3`r Al 46N' S C onnT CrL _ 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 of 20 a
Zb�mm�ission
Seal
xpires
FDurhZACHARY MINER
Notary Public
Co., North Carolina
am
ommission Expires May 8, 2027