NCC230664_FRO Submitted_20230313

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
`/`% I 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
NORT-H <.4RU1 INI I 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 Lot 4 Grand Highland Estates
2. Location of land -disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Streeprand Highland WayLatitude 36,026845 Longitude-78.592512
3. Approximate date land -disturbing activity will commence: 2/13/23
4
Type of development (residential, commercial, industrial, institutional, etc.): Residential
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 arise during land -disturbing activity:
Name Matthew Kerul E-mail Address [e-mail]
Telephone [phone] Cell # 770-286-1013 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Braswell Custom Homes Inc 919-578-2945 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 40159 3908 Blackard Pond Rd
Current Mailing Address
Raleigh NC 27629
City State
8. Deed Book No. 019254
Part B.
Current Street Address
Raleigh NC 27604
Zip City State Zip
Page No. 00134 Provide a copy of the most current deed.
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):
Braswell Custom Homes Inc
Name
PO Box 40159
Current Mailing Address
Raleigh NC 27629
City State Zip
Telephone [phone]
matthew(a)braswellcustomhomesinc.com
E-mail Address
3908 Blackard Pond Rd
Current Street Address
Raleigh NC 27604
City State Zip
Fax Number N/A

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
E-mail Address
Current Street Address
State Zip City
Telephone 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
Parity is a Corporation, give name and street address of the Registered Agent:
L� 5ru`S r0V1 C 6ra.5W_lI cvstow.,�'o"..Siv"C.
Name of Registered Agent E-mail Address
Po 46ox 4 D I A
Current Mailing Address
City State Zip
Telephone 11� - S 7g' ' Zliyj
3109 9111,KC-z Pa^'� k._�
Current Street Address
/L'(!:; L� AIL. Z.76 014
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
corrected information should there be any change in the information provided herein.
Matthew Kerul
Type or print name
Operations Manager - Braswell Custom Homes Inc
Title or Authority
1 /23/23
Date
I, ,U.a , \ 1 �� �� a Notary Public of the County of
n
State of North Carolina, hereby certify that f� �.0 �'�'t�! ���' (\'.�, appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and.eglprial seal, this _day of ar " 2OIL—
TA
Notary
:Seal
My commission expires /
B\G "%.
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