NCC230708_FRO Submitted_20230316

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may utrtate any Land -disturbing acbv4 on one or more acres as covered by the Wake
WAKECounty Unified Development Ordinance before this foam and an aceptadle erosion and
77C:UU sed.,mentatior control pion have been completed and approved by Wake Cwnty Department of
' Environmental Services Water Quality Division. (Please type or pant and, ff the quesbon is not
applicable. place NIA in the blank)
Part A.
1. Protect Nate
2 Location of land -disturbing actively: JufisdDrtion ��' (Waite C or Municipality)
Highway/Street � 'u Latitude �1 L `-{ Longiwde J%� • � to Z 5 7
3. Approximate data land -disturbing activity wifl commence: r I QV - I + l
4. Type of development {residential, Corrrntisrcial, industnal, institutional, etc.): _ft '}&11t1T`f-A
5. Total acreage disturbed or uncmered {including off -site utilities and borrow/waste
areas- r .7
6 Person to contact should erosion and sediment control issues arise during land -disturbing activity-,
Name `, ti Lti l�t ]iS{ �? E-rrii Ad�fress 1.� "�'�C�'rl C : CSC .:�: r rrlC1•C� r rti
Telephone CA l S :zc l- '�; 6 -Lc: Cell #
t . Fax # .'
7 Landowrier(s) of Record (attach a=mpanied page to lest additmal owners):
t
�' 1't an rt ��f•C�t� Lu
Narr`,e1,s'l
717 Cc r yr
Current Mailing Address
city Slate Zip
"(icy 71f S 067
Telephone Fax or E-mail address
Current Street Address
city
State
Zip
a Deed Book No. Page Na. �' ? Provide a copy of the most current deed.
:FT4:1
Personf s) or fi"%7 who are finanr iaily responsibie for the larod-disturbiing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. include requested information):
is 1 ►� 14��t�■ �`' �Li �C..ti,�ltr� C.`L��1��L� r_CCx�r�
Name E-mail Address
17 Ccr►r,,A\t L
Current Maiting Address
City State ,Zip
Te"hone `1 7 `f S C. E `ZC
4`
Current Street Address
t4 t�
City State zip
Fax Number 1 L

(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 Eresion and Sedimentation Control Ordinance and°or Land
Disturbance Permit
Name
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number.
State Lip
tbl If the Financially Responsible party 1 a Partnership or other person engaging in business under ar
assurnod name, attach a copy of the Certificate of Assumed Name.tf the Financially Responsib;o
Party is a Corporation, give $me and street address of the Registered Agent
r`
Name of Registered Agent E mail Address
Current Wailing Address
City State Zip
Telephone
Current Street Address
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
Type or riot narn
4
Sig7-
nature
Title or Authority
IG
Date
7 ;I"xt'(f % 1' ;�. ',�? a Notary Public of the County of
State of North Carolina, hereby certify that f0 1 /r' + r� k r � appeared
personalty before me this day and being duly sworn acknowfedged that the above form was executed by him
Witness my hana and notarial seal. this .day of 20
jJOArALET G ROSATQ I:q.A.c 8K.'a., '��
�N;riary Public,, iV rY 77.7
S 1-�
i-Ke CO.. Norrh n.;,tirojina
My COmmissicn ExPOCS Dec. 21, K21, My commission expires