NCC223068_FRO Submitted_20220829

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
SNAKENo 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Church Street Day Care Center
2. Location of land -disturbing activity: Jurisdiction Morrisville (Wake Co. or Municipality)
Highway/Street Church Street Latitude 35.833389 Longitude-78,835828
3. Approximate date land -disturbing activity will commence: March, 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.55
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity. -
Name John A. Woodlief E-mail Address Iohn.woodlie€@bnkinc.com
Telephone [phone] Cell # [phone] Fax # [phone]
7 Landowner(s) of Record (attach accompanied page to fist additional owners):
Smyle Investments 919-924-2991 [e-mail]
Name(s) Telephone Fax or E-mail address
633 Mercer Grant Drive 633 Mercer Grant Drive
Current Mailing Address Current Street Address
Cary NO 27519 Cary NO 27519
City State Zip City State ZIP
8. Deed Book No. 17561 Page No. 1722 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):
Sudhakar Upadhyaya [e-mail]
Name E-mail Address
633 Mercer Grant Drive 633 Mercer Grant Drive
Current Mailing Address Current Street Address
Cary NC 27519 Cary NC 27519
City State Zip City State Zip
Teiephone 919-924 2991_ 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. -
Name
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State 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
E-mail Address
Current Mailing Address Current Street Address
City State Zip
Teleph
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.
Sudhakar P Upadhyaya
Type or print name
Signature
Managing PartneT
Title or Authority
2/15/2021
Date
i, a Notary Public of the County of
State of North Carolina, hereby certify that �U&a LQY U _ appeared
personally before me this day and being duly sworn acknowledged that the above fo m was executed by him.
Witness my hand and notarial seal, this_':�jday of , 24
r APARAJITA SINGH Notary
Notary -Public, North Carolina
ke CountyMy commission expires �1 14 2b��fissiE
My Corn on Expires