NCC223819_FRO Submitted_20221115

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WASNo person may initiate 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
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
2. Location of land -disturbing activity: Jurisdiction V4tnij l I (Wake Co. or Municipality)
Highway/Street Q,Y n,(b Latitude Longitude N4
3. Approximate date land -disturbing activity will commence: 1.%
4. Type of development (residential, commercial, industrial, institutional, etc.):'RQ<S &Y1,-W
5. Total acreage /']� disturbed or uncovered (including off -site utilities and borrow/waste
areas): LL.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name �01J�1�'1 } �� E-mail Address 1' C �-1V(�� � 1/�1 Y1 ('QYVA
Telephone C� 16� 4 L0- 2q `4 3 Cell # 9 Iq -1qP _ b 3 (3 Fax #
7. Landowner(s) of Rie-cord (attach accompanied page to list additional owners):
Name(s) Telephone Fax or E-mail address
lobo Aev a.i Ge►j�6,(P 1,10
Current Mailing Address Current Street Address
1 Q .� dl0 (_ 2-1 SL'a o
City 0 State Zip City State Zip
8. Deed Book No. 2oZ0 Page No. 1709 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 E-mail Address
-�?_o-X Ika"? (�eyE' jj 2D1 ` �1 r ,�.
Current Mailing Address Current Street Address
2a it a A- N c' 021 w s
City P
i State Zip
Telephone q �1(�1-a i (,-3
City
Fax Number
State
0

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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone 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.
_-UxfIS � N PDT r5 9 - m ►h S}�r
Title or Authority
MI Al 20?_2
Date
1, a a Notary Public of the County of
a'M
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledge4 that the above form was executed by him.
IQ Witness my hand and notarial seal, this day of A� 20
l
Notary
SealJanis Perez
NOTARY PUBLIC My commission expires
Johnston County
North Carolina
My Commission Expires August 4, 2026