NCC231354_FRO Submitted_20230508

111.1.1 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE 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
COUNT`3( sedimentation control plan have been completed and approved by Wake County Department of
FORTH CA O �,:;. Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. y
1. Project Name KO I Ca S' ` &\IS jc)6 1 :),cam
✓i r
2. Location of land-disturbing activity: Jurisdiction 1 Cw0A c,-t i o—641. Wake Co. or Municipality)
Highway/Street 1lt?Gt> AC.SV.Al .9.d Latitude 35. 5305 Longitude '1 1. 21-,253
3. Approximate date land-disturbing activity will commence: ii5P
4. Type of development (residential, commercial, industrial, institutional, etc.): -Res Iricn--hc .l
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): L_ ii.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1 i(CtCzt,,-.v1S E-mail Address imci CIS 1 @a+( hufon .COrvl
Telephone C\ L(C\1 -,a11,E Cell#CO-L15'1-:t143 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
17.". . 1- 0►e-t•c+- Inc 161'y 1`1- 01U3
Name(s) Telephone Fax or E-mail address
200C Ae r iCd('e rt-1 CrPG.1,1,Siuil0A
Current Mailing Address Current Street Address
11ACf (ISf\11e NC 015ce )
City State Zip City State Zip
8. Deed Book No.11 gk-10, 120.1 Page No. 1155, 22Z8 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):
-71): 1), 140v'-k ) Nc--1 rckccc, v\s ndclvi% 11clr1,N6r-kv- .a,v,
Name Li E-mail Address
120E Cal tso-Pi\lb,b R_ciSt Dl
Current Mailing Address Current Street Address
a(1.1.Ac& NL- a1L,l
City State Zip City State Zip
Telephone °I ICI,LIc1-g I3 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone _ 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 theinformation provided herefin.
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Typt or print riAme Title or Authority
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Signature D Date
I, \a i-Q. , a Notary Public of the County of
State of North Carolina, hereby certify that i(CC...- r. kv\S appeared
personally before me this day and being duly sworn acknowledgbd that the above form was executed by him.
Witness my hand and notarial seal, this day of_OvY , 20c3
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NOC (Jo My commission expires
Nmmissionust 4,2026