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HomeMy WebLinkAboutNCC232318_FRO Submitted_20230803 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 fine D be b erosion COUNTY sedimentationCountyUni ed control planevelopment haveOrdinance been completedefor and this approvedform byand an Wake Countyaccepta le Department ofand �,� 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 Lot 4 Calvin's Mill 2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality) Highway/Street Grist Stone Way Latitude 35.916 Longitude -78.383 3. Approximate date land-disturbing activity will commence: 5/22/2023 4. Type of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): .376 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Shane Young E-mail Address construction@gemstonehomesnc.com Telephone 919-355-6549 Cell# Fax# 7. Landowner(s)of Record (attach accompanied page to list additional owners): Gemstone Homes LLC 919-355-6549 Name(s) Telephone Fax or E-mail address 206 Raleigh Street Current Mailing Address Current Street Address Fuquay Varina NC 27526 City State Zip City State Zip 8. Deed Book No.019267 Page No. 00474 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): Gemstone Homes LLC construction@gemstonehomesnc.com Name E-mail Address 206 Raleigh Street Current Mailing Address Current Street Address Fuquay Varina NC 27526 City State Zip City State Zip Telephone 919-355-6549 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: Christopher Schiavone construction@gemstonehomesnc.com Name of Registered Agent E-mail Address 206 Raleigh Street Current Mailing Address Current Street Address Fuquay Varina NC 27526 City State Zip City State Zip Telephone 919-355-6549 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. Christopher Schiavone President Type or print name Title or Authority 5/18/2023 Signature Date I, ,k (\ 1 `7\kcck , a Notary Public of the County of )&4- — State of North Carolina, hereby certify that Q cl sk-v-p'hL_1 `�� 't� �/c�l� 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 ,tSay of 320 �i3 lr;ta S-a JULIE M BYRD My commission expires 1/l / 7-0 2-3 Notary Public Wake County,North Carolina My Commission Expires 07/24/2023