NCC222871_FRO Submitted_20220822

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
WEE
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 Pathway Triangle
2. Location of land -disturbing activity: Jurisdiction Morrisville (Wake Co. or Municipality)
Highway/Street McCrimmon Pkwy Latitude 35.846159 ongitude-78.818007
3. Approximate date land -disturbing activity will commence: September, 2022
Commercial
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreaqe disturbed or uncovered (including off -site utilities and borrow/waste
areas): 38.1
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tim Skender E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
King Combs, LLC [phone] [e-mail]
Name(s)
800 Boylston Street, Suite 2400
Current Mailing Address
Boston, MA 02199
City
Telephone
800 Boylston Street, Suite 2400
Current Street Address
Boston, MA 02199
State Zip City
8. Deed Book No. 18686
Part B.
Page No.
:�I
State
Zip
Provide a copy of the most current deed.
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):
BE&K Building Group, LLC (and Attached) [e-mail]
Name E-mail Address
100 Capitola Drive, Suite 301 100 Capitola Drive, Suite 301
Current Mailing Address Current Street Address
Durham NC 27713 Durham NC 27713
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:
Corporation Service Company
Name
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh
City
NC 27608
State Zip
Telephone [phone]
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
Raleigh
City
Fax Number
NC 27608
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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh NC
City
Telephone.
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
27608 Raleigh NC 27608
State Zip City State Zip
[phone] 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.
Sr. Project Manager
Title or Authority
'PVj e I a I
Date
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I, I-Akw_v 13AZD . , a Notary Public of the County of W A 1<15'
State of North Carolina, hereby certify that 1&-i I "A L-W-/ 0 - appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my�notarial seal, this;!, I
q
C Y L.
NOTA&
Seal
P41EJ L I C
day of -VL-Y _, 20 7,-2-
Notary
My commission expires

Part B. (Continued)
Branch Civil, Inc. [e-mail]
442 Rutherford Ave, NE
Roanoke, VA 24016
[phone]