NCC223093_FRO Submitted_20220916

15�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=7 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty 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 Martin Pond Road - Road Widening
2. Location of land -disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Martin Pond Road Latitude 35' 46' 18" N Longitude 78'25' 3" W
3. Approximate date land -disturbing activity will commence:
Winter 2022
4. Type of development (residential, commercial, industrial, institutional, etc.):
Transportation
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.76
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Chris Ferraguto E-mail Address chrisFerraguto@brookfieldpropertiesdevelopmentcom
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Nash Wendell Falls, LLC
Name(s) Telephone Fax or E-mail address
4020 Westchase Blvd, Suite 150 Same as Mailing Address
Current Mailing Address Current Street Address
Raleigh NC 27607 Same as Mailing
City State Zip City State Zip
8. Deed Book No. 015478 Page No.1623 Provide a copy of the most current deed.
Part B.
I. 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):
Nash Wendell Falls, LLC [e-mail]
Name E-mail Address
4020 Westchase Blvd, Suite 150 Same as Mailing Address
Current Mailing Address Current Street Address
Raleigh NC 27607
City State
Telephone [phone]
Zip City State Zip
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
E-mail Address
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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.
Tanya Matzen
Authorized Signatory
Type or print name Title or Authority
,-)Lk Le I �7
Signature Date
I, AYAU L a Notary Public of the County of n
State of North Carol a, hereby certify that t_Z C*-1 appeared
personally before me this day and being duly sworn acknowled d that the above form was executed by him.
Witness my hand and notarial seal, this day of 20 2-C&
KI,N,GR,lrf
. - - .'.�y otary
Seal piAiq My commQison expires
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