NCC230685_FRO Submitted_20230317

lw�w 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
NOR Ili Environmental Services, Water Quality Division. (Please type or print and, if the question is not
- applicable, place NIA in the blank.)
Part A.
1. Project Name The Overlook at Stoney Creek
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Hurry 50/Benson Rd Latitude 35.6486 Longitude-78.6125
3. Approximate date land -disturbing activity will commence: 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 37-16
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Mark L. Maynard Sr.,
Name Overlook at Stoney Creek LLC E-mail Address [e-mail]
Telephone[phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Overlook at Stoney Creek LLC 910-338-3585
Name(s) Telephone Fax or E-mail address
332 Military Cutoff Rd. 332 Military Cutoff Rd.
Current Mailing Address Current Street Address
Wilmington, NO 28405 Wilmington, NO 28405
City State Zip City State Zip
8. Deed Book No. 18411 Page No. 0925 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):
Mark L Maynard Sr., Overlook at Stoney
Creek, LLC [e-mail]
Name E-mail Address
332 Military Cutoff Rd. 332 Military Cutoff Rd.
Current Mailing Address Current Street Address
Wilmington, NO 28405 Wilmington, NO 28405
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:
Patrick Barbeau, Timmons Group [e-mail]
Name E-mail Address
5410 Trinity Road; Suite 102 5410 Trinity Road; Suite 102
Current Mailing Address Current Street Address
Raleigh, NC 27607 Raleigh, NC 27607
City State Zip City State Zip
Telephone [phone] 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 E-mail Address
Current Mailing 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 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.
Mark L. Maynard Sr,
Type or print name
Signature
Manager
Title or Authority
Date
I, i'��,� C�,�� a Notary Public of the County of
State of North Carolina, hereby certify that I-A04CY__ k-kgI 'Z�a , mac._ appeared
personally before me this day and being duly sworn acknowledged that the ab&e form was executed by him.
Witness m h �k
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