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HomeMy WebLinkAboutNCC223645_FRO Submitted_20221025WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land -disturbing activity on one or more acres as covered by the Wake WAUCounty 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 hnIII ,i CAROL IN'A 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 I o r��{0A b( dt Lb t D--0 .i j J 2. Location of land-disturbin activity: Jurisdiction i Q (Wake Co. or Municipality) Highway/Street Latitude '�8. V V 3 Longitude — � .j�f7 3. Approximate date land -disturbing activity will commence: 4. Type of development (residential, commercial, industrial, institutional, etc —TA, 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas):_ O.4 36 6. Person to contact shoulderosionand sediment control issues arise during land -disturbing activity: Name I i� !�,Jr bLpoP. E-mail Addressf� r�.o�r�Qsh'QMC Telepho Cell A I q - �/o1 -1p 033 Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): —) I, I -�l t t 4 -% " De, (I t q ­'iq 0 - q Name(s) Telephone S, Lbr ksJ Current Mailing Address Aqli,ok i L A-74 u� City State ,Zip Current Street Address City State Fax or E-mail address Zip 8. Deed Book Not ( 6i n SGj Page No.'s-'-) �� to Provide a copy of the most current deed. Part B. 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): Name I &mail Address Current Mailing AddressCurrent Street Address f / city State Zip City State Zip Telephone G 1 q-i� 4 u- q 21 z 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 Current Mailing Address E-mail 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. r IFf U i,o0.t� 1 it/cS�o►L Type or print 6ame Title or Authority J6f13 Signduke Date �/-J44'Z, , a Notary Public of the County of IAJ State of North Carolina, hereby certify that 212 L �kYa appeared personally before me this day and being duly sworn acknowledged fhat the above form was executed by him. Witness my hand and notarial seal, this LANA THERESA A. TREFFTZS Notary Public Wakes arty, North Carolina My Commission Expires March 6, 2024 3Lday of , 20 D t Notary My commission expires Nryo c9 0-