NCC222938_FRO Submitted_20220817

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W�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
NORTH CAROLINA 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 Novel Morrisville
2. Location of land -disturbing activity: Jurisdiction Town of Morrisville (Wake Co. or Municipality)
Highway/Street Southport Dr. Latitude 35.837719 N Longitude 78.816750 W
3. Approximate date land -disturbing activity will commence: May 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential Mixed -Use
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 11.93 AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name f)P) &rAV'J+1e.f'1 E-mail Address �� L�fir+ 3CY'e5.ow�w��nh�CV_'
f1 �' tul�
Telephone K—,-) So-gQ3 Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Ammons East Corporation 919-453-0175 919-453-0178
Name(s) Telephone Fax or E-mail address
140 Ammons Drive 7200 ACC Blvd STE 101
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27617
City State Zip City State Zip
8. Deed Book No. 018157 Page No. 01142-01149 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):
q Cr cc-+C-0t-)M .fn, -)4 0 Cs_ cow,
Name E-rh6il Address
601 S.. 'Tr g'n '54, go 0 C,01 1'_ ` i r.jon S4- 8O 0
Current Mailing Address Current Street Address
Lrr1:��c
City State Zip City State Zip
Telephone 1_S— LU aq 3 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: bc, +
Name 6�1! c. ��� C�l�.
E-mail Addcbss
Current Mailing Address Current Street Address
O l 37 s - 5ffm�
City State Zip City State Zip
S' �3[gI�i Fax Nj
Telephone � � �umber
(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:
-dame of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
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.
NT-CE A EL SU P R i D `�
Type or print
ignature
AO'T R_1_ � D SAC -,tom �L
Title or Authority
IZ 11-311 21
Date
I, 7XP4 ,9 6V,,W S , a Notary Public of the County of lveez_*' _
State of North Carolina, hereby certify that /I/!ZIIM� W1411� T appeared
personally before me this day and being dully sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this Ads day of 4 2p
TER] A. EDWARDS Notary
N!glay�l Public, North Carolina
rvlecklenburg County /�%
i My Commission Expires My commission expires
May 07, 2025