NCC232236_FRO Submitted_20230727

MP" WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
TA No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
I 1 S.E County Unified Development Ordinance before this form and an acceptable erosion and
I 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
NORTH CA ROLINA
applicable, place N/A in the blank.)
Part A. f�
1. Project Name c �`t �4^� i Cm3 l,/�dh St) oak
2. Location of land-disturbing activity: Jurisdiction ‘.,lctk _ (Wake Co. or Municipality)
Highway/Street-Jc:Y1/4'cj5 (•-.".As Latitude 3' -ci 66)63 3941757
Longitude `
3. Approximate date land-disturbing activity will commence: -: .>
4. Type of development(residential, commercial, industrial, institutional, etc.): 4---esAtAficIlot
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .98 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:„
Name D.0 4Yv�S V� \ L E-mail Address e. A e1i^'� Y"tka " ' ' d
Telephone Cell# 91 ' 1 ' 1 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
t4t0n ,(VN (.4 Vim^ k [phone]. [e-mail]
Nae(� � �Yv, . � Telephone Fax or E-mail address
—NCO C CO "Vir-=, U1S
Current Mailing Mdress Current Street Address
City State Zip City State Zip
8. Deed Book No. ' 5-3 I Page No. 1101 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):
elVittir4-4 At 5 ; IAA/ tuwie.:5 Mei ef
Name 1 E-mail Address
Current Mailing Address Current Street Address
111A(if,citNe,44 Af )401
City State Zip City State Zip
014 t.i 3�.y i
Telephone E- � 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:
Matthew Baldwin [e-mail]
Name of Registered Agent E-mail Address
401 Wait Ave
Current Mailing Address Current Street Address
Wake Forest NC 27587
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 here"n.
0/44 ) fri nti 4,440,(CIL,j)vl men
Type o print n Title or Authority
Signature Date
I, P AJi'coL Ccddt f I , a Notary Public of the County of (*nit'n
State of North Carolina, hereby certify that n70r1f Ra(dwiin 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 l , 20 21
��.!'
Notary
P. NICOLE RAY CADDELL My commission expires M I/ 2 Dal
NOTARY PUBLIC
Franklin County
North Carolina
My Com[ rninExpiresc/ussio f b2'