NCC230148_FRO Submitted_20230119

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
N'0'i CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
A.
P1. art Project Name �49 ffi/fia/
Z Location of land -disturbing activity:/ Jurisdiction �(, per,&,- C�G✓N1 J (Wake C%o..(or Municipallii�t'y�)
Highway/Street t � l t /�°t,��Latitude . f� t �5 g& Longitude _ t 8 r � � � �i ��
3. Approximate date land -disturbing activity will commence: f ' !t�
4. Type of development (residential, commercial, industrial, institutional, etc.): &�ll' w' c_
5. Total acreage di t riled or uncovered (including off -site utilities and borrow/waste
areas): i
6. Person
<to c ntact shoulderosionand sediment control issues arise
(during
%land -disturbing activity:
Name E-mail Address
Telephone (' TSO Cell # (� � J Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
�fo - V_k�- 7�cl
Name(s) j/J % Tellle?MWI�'X'v
phonne fFax or E-mail address
�jrf '
Current Mailing Address s Current Street Address
9 IN, /�// �� zk_k �' JR&Y At ZW-43
City ( State Zip City State Zip
3. Deed Book No. 1��i Page No.�— 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
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Njame �(
Current Mailing Address
City �S"tate Zip
GIV
Telephone �( 66 -
E-mail Address
a
'�Itloof IT
Current Street Address
z,7
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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
co�wcted information should there be any change in the information provided herein.
At �6/Lvx-- 'AIM N11K—
Type r' t me Title o Authority
Signature v Date
1, &&Aal �i^t'ot_ i �,; �{� a Notary Public of the County of ( Ake—'
State of North Carolina, hereby certify that ilT�- Q4 I V r- appeared
personally before me this day and being duly sworn acknowledged tPia the above form was executed by him.
Witness my hand and notarial seal, this _bday of JVt120 Z 2.
'' ORfA ',,
•,.+P ,�. tip'..
OTaRJ- Notary
Q .�+ '
Hamm. Exp. Z q
09/26/2027 My commission expires
it �'•.,� � �,� ,. r �' ,��