NCC223648_FRO Submitted_20221025

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 sedimentation control plan have been completed and approved by Wake County Department of
NORIN CART?!.lNA 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 9608 Chris Dr
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Chris Dr Latitude_ 35.6495 __ Long itudes-78.6943
3. Approximate date land -disturbing activity will commence: 9.13.22
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered icluding off -site utilities and borrow/waste
areas): 0.7
6. Person to contact should erosion and sediment r itrol issues arise during land -disturbing activity:
Name Mike Hamilton E-mail Address [e-mail]
Telephone [phone] Ce!1 # Fax #
7. Landowner(s) of Record (attach accompani ed page to list additional owners):
Frank Barbee 919.795.0953
Name(s)
Telephone Fax or E-mail address
120-A N salem St
Current Mailing Address
Current Street Address
Apex NC
27502
City State
Zip
City State Zip
8. Deed Book No. 19134
Page No.
301 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):
Chamberlain Homes LLC
[e-mail]
Name
E-mail Address
120 A-N Salem St
Current Mailing Address
Current Street Address
Apex NC
27502
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:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number
(b) if the Financially Responsible Parry 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 attomey-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.
Frank Barbee
Type or ' t name
Signature
Manager
Title or Authority
10.17.22
Date
I, 114�Cj I G M• G 5 , a Notary Public of the County of w/ G(��
State of North Carolina, hereby certify that f i r'1 1`� YJdz 1C- 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 I day of 20--
I
Nota
OFFICIAL SEAL My commission expires "l l "-oC ��
Notary PubUo, North Caroling
County of Wake
NATALIE M. FRANCIS
My Commisson Expires