NCC223039_FRO Submitted_20220829

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
i No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKE! County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY I 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 Lot #34 Heather Glen (5409 Whistling Duch Ct., Raleigh, NC 27603)
2. Location of land -disturbing activity Jurisdiction Wake County (Wake Co or Municipality)
Highway!Street — Latitude 78.617205 Longitude 35.628385
3. Approximate date land -disturbing activity will commence: Aug. 15, 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) 0.31
6 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Russell Hart E-mail Address cycpresshomesnc47,gmail.com
Telephone [phone] Cell #
Fax #
7 Landowner(s) of Record (attach accompanied page to list additional owners).
Russell Hart 919-762-6556 cypresshomesncr:gmail.com
Names) Telephone Fax or E-mail address
PO Box 37143 2825 Orchard Meadow Ct.
Current Mailing Address Current Street Address
Raleigh, NC 27627 Raleigh, NC 27606
City State Zip City State Zip
8. Deed Book No 016440 _ Page No 02045 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):
Russell Hart cypresshomesnc,u gmail.com
Name E-mail Address
PO Box 37143 2825 Orchard Meadow Ct.
Current Mailing Address Current Street Address
Raleigh, NC 27627 Raleigh, NC 27606
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:
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 State
Telephone
E-mail Address
Current Street Address
Zip 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.
Russell Hart
Type or print name
12t
Sign ture
President
Title or Authority
�Y'3D-ZG
Date
13USU �' Q IYIM a Notary Public of the County of , U
State of North Carolina, hereby certify that Q.U.MI qa � appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand seal
O T'q
_• Comm
Xlea7-12 XP.
-2 2
.,,Fj�,•••...,....... A, •o\
this bo day of I 20 _
rM
'�0�A
�t
y
yommission expires