NCC232062_FRO Submitted_20230711

"WI 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
WAKECounty 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
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 Namn Lot 17, Grand High! states, 1641 LEGACY RIDGE , WAKE FOREST, 27587
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Latitude 35.954510 Longitude -78.510900
3. Approximate date land-disturbing activity will commence: June 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joshua B. Mauney E-mail [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Paragon Building Group, Inc. 919.329.000E
Name(s) Telephone Fax or E-mail address
829 Purser Drive 829 Purser Drive
Current Mailing Address Current Street Address
Raleigh, NC, 27603 Raleigh, NC, 27603
City State Zip City State Zip
8. Deed Book No. Page No. 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):
Paragon Building Group, Inc. [e-mail]
Name E-mail Address
829 Purser Drive 829 Purser Drive
Current Mailing Address Current Street Address
Raleigh, NC, 27603 Raleigh, NC, 27603
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:
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:
Joshua B. Mauney [e-mail]
Name of Registered Agent E-mail Address
829 Purser Drive 829 Purser Drive
Current Mailing Address Current Street Address
Raleigh, NC, 27603 Raleigh, NC 27603
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, b an officer, director, partner, or registered agent with
uthority to execute instruments for t inancially Responsible Person). I agree to provide
correct information Id there change in t ation provided herein.
/ ir....er .C-t t:,vt2 c
e or print na Title or Authority
6'2773
igrsa`fur Date
I, < )\fle,rf I \ T T , a Notary Public of the County of 4V-4"
State of North Carolina, hereby certify that -- )`S~-)c, (r1GL) 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 R-7 day of , 20 Z-j
Not
Seal
My commission expires "4
SHERRIL T PNtLAN
NOTARY PUBLIC
Wake County
North Carolina
I',ty Commission Expires 01/02/2025