NCC223229_FRO Submitted_20220916

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERS HIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
�, , No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
�T 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
110M if f AV N& 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 Lei- 8 ,1 6L Vf inc, t
2. Location of land -disturbing activity: Jurisdiction (Wake Co, or Municipality)
HighwaylStreetlgOD_Vte, l Ot�5CZLAV LatitudeLongitude
3.
4.
Approximate date land -disturbing activity will commence:
Type of development (residential, commercial, industrial, institutional, etc.): JzCr.`dA'A4
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): e —IC5
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name C tiS E-mail Address I 'S �AW�
TelephonAi4l., - 0(ootp -.' 0c ) Cell # Fax # q
Landowner(s) of Record (attach accompanied page to list additional owners):
fi ll S P,v�iO4 Conl'}a�ed 2sf 1 s- � - W3 -3z'42- wi l 41a� s
Name(s) Telephone Fax or E-mai address
Current Mailing Address Current Street Address
L4+ �J(- 2V4
City State Zip City State Zip
$. Deed Book No. 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
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Name E-mail Address
44"
Current Mailing Address
_ Z7n)q
City State L Zip
Telephone ��" �`� ---&
�M.
Current Street Address
City
Fax Num
State
Zip

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 E-mail Address - T
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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.
atop. � ! � a_�. �` �� �,�c��.�e✓
Type frilnam Title or A thority.
Gi
Sianature Date(
A- , a Notary Public of the County of H4I1 4LY
State of North Carolina, hereby certify that 14 rVXJ d-, ThA.a '1 t, W AkS 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 1*1_�Iday of �'�AC.L , 20 ZZ--
INOTA
A. KILLIAN
I�Y ptJ�t_lGNo y
seal RG(711t�TY, NC ! v��JJ
My commission expires 0�24