NCC230848_FRO Submitted_20230404

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
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 CRAOLlNA 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 Timber Drive Widening (East)
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Timber Drive (East) Latitude 35.68425 Longitude -78.57417
3. Approximate date land-disturbing activity will commence: 03/23/2021
4. Type of development(residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.84 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rich Barta E-mail Address richna coreproperties.corn
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Garner Land Company LLC
Name(s) Telephone Fax or E-mail address
C/O Collett&Associates Inc PO Box 36799
Current Mailing Address Current Street Address
Charlotte NC 28236-6799
City State Zip City State Zip
8. Deed Book No. 8841 Page No. 198 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):
Garner Land Company LLC richtcoreproperties.com
Name E-mail Address
831 E Morehead St#445
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number 004) (n• 9

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:
Brad Connolly bconnollyccr�burtoneng.conn
Name E-mail Address
130 Partlo Street
Current Mailing Address Current Street Address
Garner NC 27529
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:
Rich Barta richZ;coreproperties.com
Name of Registered Agent E-mail Address
[e-mail] 831 E. Morehead St. Suite 445
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
Telephone[phone] 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.
A IN
Ty e ' t ame Title or Authority
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Signa Date
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I, 6') 1 or) , a Notary Public of the County of /retklenbl/Lr -
State of North Carolina, hereby certify that +)Di;r appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of I arch , 20
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