NCC223404_FRO Submitted_20221003

Part A,
1.
.
3,
4.
VVAKE COUNTY FINANCIAL RESPONSIBILITY)OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may i n it i ate 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
sedimentation control plan have been cem pi eted and approved by Wake County Department of
Environmental ,services, Dater Quality Division. (Please type or print and. if the question is not
a pp lira ble, place NIA i n the h la nk . )
Project Name 0612 Curia Dr
Location of land -disturbing activity. ,Jurisdiction
Highway/Street
Chris Dr
Latitude
Wake
3:5.6495
Approximate date land -disturbing act Vity will commence:
(Wake Co. or Municipality)
Longitude
Type of developmeflt (residential, commercial. industrial, institutional. etc,):
-78: 94
I esidentia
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas); 0.9
6. Person to contact should erosion and sediment control issues anise d ud og land -disturbing activity:
Name Mike Hamilton
E-mail Address mike@barbeeconstructionse i s.corn
Telephone 91 g .389.8197 Cell # Fax #
7. Landowner(s) of Record (attach acoorrnpainled page to list additional ownars):
Chamberlain Domes
Name(s)
120-A N s a lem St
Current Mailing Address
919-795.09 3
Telephone
Current Street Address
Apex NG 2750
City State zip City
1 g-E
S. Deed Book No.
Part B.
Page No.
1134
State
Fax or E-mail address
9[
Provide a copy of the most current dead.
1. Per r (s) or firm(s) who are financially responsible for the land -disturbing a tivity (Provide a
comp rehensive list of all responsib le p arties c n an atta shed sheet. I n c l ud a req uested information)
Chamberlain Homes LLC [e-mail]
Name
120 A-N Salem St
Current Mailing Address
E-mail Address
Current Street Address
Apex NC 27502
City State ZIP City State Zip
Telephone 919.796,09-53
Fax Number

2 _ (a) If the Financially Responsible Party is not a resident of Wake ke ou nt }, ad a nt Gfy a designated agent in
Wake County to receive any notice. Process, pleading in any action or legal proceeding arising out of any
matter retaling to the lake County Erosion and Sedimenlation Control Ordinance andfor Egad
Disturbance Permit
Name
Cur -rent Mailing Address
City State Zip
Telephone
E-mail Address
urrient Street Add r-ss
City -- State ZP
Fax Number
(b) If the Financially Responsible Party is a Partnership or other parson engaging irn business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a CorpDration, give name and street address of the Registered Agent;
Marne of Registered Agent E-maii Address
urrent Mailing Address
city State Zip
Current Streel Address
City
Telephone Fax Number
State
Zip
The above information is true and correct to the best of mar knowledge and be[lef and was provided
by me render oath (This form must be signed by the Financially Responsible Person if are individual
or his attorney -in -fact, or l f not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Peron). J agree to provide
corrected information should there be any change in the information provided herein.
Frank Barnee
Type or t name
ignatu re
1. N Etta 11` r Yet.
owner /Manager
Title or Author-t
Notary Public of the Count y of
State of North Carolina. hereby cer'lify that ' #�.� � � C) �- t � ;� appeared
personally before me this day and being duly swom acknowledged that the above forr'r`ti was exeout�d by hire.
Witness my hand and notarial seal. thise---daSp of �.l
Seal
J� OFFICIAL SEAL
NDUUY PobVe, North Cwoltn
ATALIE M. UJANCIS
My ommisson Expires
Nola
My commission expifec; C� I -'C�)' &Q C/